• LIBRARY OF CONGRESS. 

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UNITED STATES OF AMERICA. 



THE ELEMENTS 



C) F 



SURGICAL PATHOLOGY 



W I T II 



THERAPEUTIC HINTS 



B Y 



JAMES G. GILCHRIST, A.M., M. D. 

it 

PROFESSOR OF SURGERY, HOMCEOPATHIC MEDICAL DEPARTMENT 
UNIVERSITY OF IOWA 



MINNEAPOLIS 
MINNEAPOLIS PHARMACY COMPANY 

1895 










COPYRIGHT, 

1895. 
JAMES G. GILCHRIST. 



Republican Printing Company, 
Printers and Binders, 

Iowa City, Iowa. 



rr 



TO MY FRIEND, 

SAMUEL CALVIN, 

PROFESSOR OF GEOLOGY, 
UNIVERSITY OF IOWA, 

THE FOLLOWING PAGES ARE INSCRIBED AND 

DEDICATED. 

AS SOME FAINT TESTIMONY OF APPRECIATION OF HIS EMINENT 

STANDING AMONG BIOLOGISTS, 

AND HIS MANY ACTS OF KINDNESS TO THE AUTHOR. 

THE DOCTRINES TAUGHT WILL NOT MEET HIS FULL APPROVAL, BUT THE 

FAIR-MINDEDNESS WHICH SO EMINENTLY DISTINGUISHES HIM, 

WILL PROMPT HIM TO GIVE A PATIENT HEARING TO ONE 

WHO DIFFERS FROM HIM, AND HIS GOOD-NATURE, 

EQUALLY AS CHARACTERISTIC, WILL 

PERMIT HIM TO ACCEPT THIS SLIGHT TOKEN OF ESTEEM 

FROM HIS FRIEND, 

THE AUTHOR. 



PREFACE 

The following pages have been written to present, or to 
attempt to do so — something systematic in the study of the 
etiology of morbid action, from the standpoint of one not in 
harmonv with very much of the teaching of the da}'. The 
current literature, as well as the text-books, assume so much. 
and are apparently so oblivious of the fact that there is wide 
diversity of opinion on this question, that something seems 
necessarv from the other side on this subject. The profes- 
sion, may be divided into two classes, the clinicians, and the 
experimentalists. The students of the laboratory may cer- 
tainly boast the largest following, but it is the worker in the 
clinic-room that must fix the seal of approval on the product 
of the former. None will be disposed to question that the 
technique of the laboratory cannot be carried out in the oper- 
ating theatre: hence ideal results are impossible. But we find 
much inharmony among the bacteriologists. For instance, 
one among very many — Dr. Alexander Wilder, in the 
June (1895) number of the Metaphysical Magazine, has this 
to say on what he calls the " Microbian Craze:"— 

" The notion that the atmosphere is forever swarming with 
germs of bacteria and other microbian products, ready to rush 
into wounds, into the lungs of every breathing thing, into our 
water and kneading troughs like the frogs of Egypt, and to 
enter the pores and through the stoppers of glass bottles, is 
purely a guess, without a solitary fact to sustain it, except 
such as are found in the interpretation wherein the guess is 



VI 



PREFACE 



taken as established fact. It is a plausible theory, but un- 
proved. We are brought, therefore, to the conclusion inevit- 
ably: The germ theory is an assumption of causes, of the 
existence of which we have no evidence, to account for effects 
which they by no means explain." 

It is impossible to present any adequate argument against 
the teaching of the laboratories, as far as it has to do with the 
practice of surgery — in a short essay, certainly" not with any 
approach to thoroughness. The attempt is here made, there- 
fore, to cover the ground somewhat systematically, com- 
mencing with an account of processes that are on the border 
line between physiology and pathology, and studying the 
development of morbid action as something due to perverted 
function, assuming that conditions leading to inflammation are 
common initiatives to all pathological states. For this reason 
it will be necessary, for the reader to go through the book 
consecutively, one chapter being intimately related to that 
which precedes it. The introduction of " therapeutic hints" 
may be considered slightly incongruous in a work of this 
pretension, but the student may find them useful. In the 
preparation of the material much is due to the advice and 
assistance of friends and associates, to none more than to Dr. 
Samuel N. Watson, of this city. My thanks are also due, 
and most gratefully rendered, to my student, Miss Grace S- 
Stauffer, for much clerical labor, and invaluable assistance 
in correcting the proof sheets. 

J. G. G. 

Iowa City, Iowa, 
August ijtk. i8gj. 



TABLE OF CONTENTS. 

Preface v 

Introduction i 

The nature, and genesis of morbid action. 
Classification of morbid action. 

I. Diagnosis . 12 

Anamnesis. Etiology. Semeiology. 

II. Prognosis 32 

Duration of life. Preservation of function. 
Preservation of symmetry. Duration of the 
case. 

III. Therapeutics . . . 38 

Adjuvant. Palliative. Instrumental. Me- 
chanical. Remedies. 

IV. Semi-Pathological States 44 

Irritation. Sympathy. 

V. Anaemia 51 

Physiological. Pathological. Ischaemia. 

VI. Hyperemia 60 

Physiological. Pathological. Plethora. 

VII. Surgical Repair 67 

Union of wounds. Defects in scarring. 

VIII. Inflammation 84 

Acute. Chronic. Semeiology. Pathology. 
Terminations. 



viii TABLE OF CONTEXTS 

IX. Suppuration 123 

Purulent secretion. Abscess, acute and 
chronic. 

X. Ulceration 137 

Idiopathic. Symptomatic. Specific. Causes 
and semeiology. 

XI. Mortification 158 

Gangrene. Necrosis. Acute. Chronic. 

XII. Surgical Toxaemia 165 

Septicaemia. Pyaemia. 

XIII. Pathology of the Lymphatics . . . . 188 

Angeioleucitis. Adenitis. 

XIV. Pathology of the Blood- Vessels . . . 201 

Atrophy. Hypertrophy. Inflammation. De- 
generation. 

XV. Pathology of the Nerves 211 

Neuralgia. Neuritis. Neuroma. Soften- 
ing. Sclerosis. 

XVI. Venereal Contagion 236 

Urethritis. Gonorrhoea. Chancroid. Syphilis. 

XVII. Lithiasis 289 

General. Renal. Uretal. Urethral. Vesi- 
cal. Prostatic. 

XVIII. Tumors 316 

Causes. Classification. 



ELEMENTS OF 

SURGICAL PATHOLOGY 



INTRODUCTION 

Of books on surgery there is no lack. All departments of 
surgical science and art seem to have received attention, and 
the student can experience little or no difficulty in finding what 
he needs, with, perhaps, a single exception. Operative and 
emergency surgery is particularly well treated, in almost num- 
berless books; special topics are the subject for many volumes 
of more or less pretensions; the medical periodicals are full of 
discussions of etiology, preventive medicine and therapeutics. 
The lack, if it be one, is in a systematic treatment of surgical 
pathology, pure and simple, from the standpoint of what may 
be called the vitalist as opposed to the bacteriologist. A very 
large number of practitioners, and students, as well are far 
from ready to accept the popular teaching with reference to 
etiology and the essential nature of morbid action, and yet are 
without any systematic treatment of the subject from their 
point of view. As one who has always been conservative in 
this matter, and formed opinions upon a basis of actual experi- 
ence, and not at all contemptible in extent— it has seemed to 
be, in a measure, an obligation to attempt something in the way 
of a systematic presentation of the question at issue, more par- 
ticularly as the results of practice, based upon these views, 
have been so eminently satisfactorv. The theory upon which 
this book is written, therefore, is that morbid action is essen- 



2 ELEMENTS OF SURGICAL PATHOLOGY 

tially a question of the organism, rather than of its environ- 
ment. To properly introduce a study of pathology on these 
lines, a preliminary discussion must be had of the nature of 
morbid action. 

An organism, we were formerly taught, was something 
provided with organs. As some organisms had many organs, 
and others were themselves a single organ, the definition was 
inadequate. It might be said that an organic body differs 
from an inorganic one, in that it has a principle of life; or, in 
other words, does not grow by accretion and move by external 
forces, but appropriates, elaborates and assimilates food for 
nutrition and moves by forces, other than chemical, operating 
within itself. It also has the property of reproduction. These 
properties call for more or less complexity of structure, and 
we find great varieties, commencing with the simple uni-cel- 
lular bodies, terminating in man, the most complex of all. If 
we analyze an organ, or an organism, we find quickly that 
there are various units to be considered. The anatomist finds 
his unit, perhaps, in the organs or grosser divisions of the 
whole; possibly in the tissues of which the various organs are 
composed. The histologist, commencing where the anatomist 
ends, finds his unit in the cell, the material unit, we may say,. 
out of which the tissue is formed. The physiologist will need 
a unit beyond this, farther back in the order of development; 
he will need a molecule or its representative. Now a mole- 
cule in physics and chemistry is something, with reference to 
the mass of which it forms a part, that represents the ultimate 
physical division of a substance — one molecule of any given 
substance, is the same as any other molecule from the same 
substance. Such a conception cannot be realized in the organic 
world, the ultimate division of any one part being utterly unlike 
that of any other part. More than that, the physiological 
analogue to the molecule is not a simple body or structure; it 
is a complex one, complex beyond our comprehension. It may, 
roughly speaking, be considered the ultimate division of mat- 
ter, in which the properties of the matter still exist; the last 
point reached in subdivision before resolution into the atoms 



INTRODUCTION 3 

of the chemist. Such cannot be a molecule, in the accepted 
use of that term. Foster suggests the word "somacule" as 

standing, to the physiologist, for the molecule of the chemist. 
Beyond this unit, is still another, which the chemist needs, the 
atom, out of the union of a number of which the molecule is 
made. Thus while all organisms, even the simplest, are com- 
plex, complexity increases with differentiation. We may state 
here, in passing, that vulnerability increases with complexity, 
just as with machinery. The simplest organisms carry out 
their life's work and reach their ultimate destiny, with far less 
interruption than those of higher and more complex organiza- 
tion. 

The organism being completed, no matter what its grade as 
to complexity, it is unstable This instability is essential, and 
well understood. Work is accomplished at the expense of 
material. The molecules, yes, the atoms of the tissues, are 
constantly wearing out or forming new combinations and their 
places filled by new ones. This constant loss, the so-called 
; - molecular death," is not uniform, either with reference to 
periods of life, or day by day. In a general way, repair of 
waste exceeds loss during the growing years of the organ^ 
ism; say from birth to full maturity, or the age of thirty 
or perhaps forty; the relation becomes somewhat disturbed 
towards the end of this period, or the last ten or fifteen years. 
For a longer or shorter time there is an equilibrium, or if loss 
exceeds repair it is not appreciable. After this, loss rapidly 
exceeds repair and soon the mere molecular death becomes a 
dissolution of the organism, or somatic death. During all these 
periods, again, the relation of waste and repair depends upon 
bodily conditions and environment; extreme changes of tem- 
perature, bodily exertion, the occurrence of disease or accident, 
all increase, for the time being, the waste, which is to be made 
good by periods of rest, under normal conditions. 

As far as we know, the life history of simple organisms is 
exceedingly uneventful; they seem to be free from any morbid 
conditions, and the emergencies are not many, under ordinary 
conditions, apart from pursuit from higher organisms in 

B 2 



4 ELEMENTS OF SURGICAL PATHOLOGY 

their search for food. As the organism becomes more com- 
plex, conditions favorable to morbid action must increase, so 
that the highest organizations, it would sometimes seem, are, 
in the very nature of things, impossible of maintaining for any 
length of time absolutely orderly function. The relation of 
one function to another is so intimate, and at the same time so 
complicated, that every moment of existence is one of peril. 
Absolute, typical, and physiological function is necessarily not 
to be looked for. If health stands as the representative of 
proportional waste and repair, which are the results of the 
orderly performance of all function, suitable nutrition, in kind 
and quantity, and proper sanitary conditions, none of the 
higher organisms can be in a state of absolute health, even for 
short periods of time together. The mere occurrence of any 
disturbance in the various associated functions of the body, 
must inevitably cause some more or less notable crisis in the 
organism. The causes for these disturbances are manifold, 
and act with varying degrees of intensity. Some of them may 
be very energetic, and yet little permanent loss and slight 
temporary disturbance ensue. Others are so insidious, or 
inconsequential, apparently, that they may even elude detec- 
tion. In fact it may be asserted, the more insignificant the 
cause, apparently, the more profound the impression. It will 
serve a useful purpose, by way of illustration, to classify all 
forms of morbid action under two heads; the traumatic and 
the idiopathic. The former would attribute ail causation to 
violence, of any degree, whereby structure is at once altered 
or destroyed. The latter would be the occurrence of morbid 
action from causes different in character, in many cases not to 
be detected, and in which the consequences are slowly devel- 
oped. Now it is well known, that the idiopathic group of 
morbid processes are much more serious, in every way, than 
the traumatic. In fact, it is often the case the immediate 
consequences of traumatism may pass away entirely and only 
after a long interval will secondary morbid manifestations 
appear. This may be due to a latent morbid action starting 
into activity under the stimulus of the traumatism; or it may 



INTRODUCTION 5 

be due to some disorderly attempt at repair, or some accidental 
occurrence during the process. But whatever the case may 
be in these traumatic conditions, is not this a notable feature 
in all morbid action : the -pathological changes commence on 
the atomic plane. All disease or morbid action is representa- 
tive of some exhibition of energy; it is not in any sense mate- 
rial. The tissue changes are the result or consequences of 
some disorderly action, something immaterial and undemon- 
strable. 

We find all forms of morbid action to be, as to design or 
result, either, constructive, destructive, or trophic. New tissue 
is produced in one case, as in carcinoma, or syphilis. In 
another case tissue is torn down, or in some way is broken up, 
as in ulceration, or gangrene. In still other cases we find 
abnormalities of growth, as in atrophy or hypertrophy. No 
matter in which one of these classes any given case may be 
placed, always we find the initial lesion, the verv commence- 
ment of the pathological peculiarity, will be in the domain of the 
microscopist. The construction, destruction, or abnormality 
of growth does not attack the whole organism, or even a whole 
organ or part at once; it commences in the microscopical ele- 
ments of the part, or even back of that, in the molecular or 
atomic constituents. 

We know how important the defecation of an organism is to 
its well-being; some have gone so far as to say it is equally so 
to its nutrition. The failure in the elimination of urine is pro- 
ductive of consequences known to all. The excretion of the 
body through the skin, lungs, intestines, kidneys and other 
important glands, is an enormous amount. The failure of any 
one must cause speedy death, if there is no compensation. All 
this elimination is secured by processes that even the micros- 
copist and chemist cannot detect; all of it has to do with the 
somacules and atoms. It is surely not hard to credit, indeed it 
seems a patent fact — that all morbid action represents some 
molecular or atomic loss, or disturbance; some question of 
nutrition or excretion. It is not unreasonable to suppose that 
with the commencement of morbid action on this elementary 



6 ELEMENTS OF SURGICAL PATHOLOGY 

plane, the causes, essential causes, are of similar character. 
This, however, has to do with a later discussion. At this place 
we may assume that morbid action is representative of some 
disturbance of nutrition (or excretion), commences on the 
atomic plane, extends to the "somacular," thence to the cellu- 
lar and so to the tissues, the organs, the organism. Nothing 
gross, as to magnitude, nor intense, as to energy is needed. It 
is not even necessary that it should be material, mere mental 
impressions, or if you please, psychic disturbance, may derange 
function, and tissue-change is then easily induced. Thus it 
may be said, although the topic will come up again later, that 
while the actual form of morbid action is determined by forces 
acting and originating entirely within the body (intrinsic), the 
incitement to such action maybe and, in all probability, usually 
is. in some force coming from without. 

However the morbid action may be set up and no matter 
what its character, duration, or intensity, there is always a 
tissue-change, a structural loss more or less irreparable. An 
organ or part once diseased, a defect remains that is perma- 
nent, although reproduction, after a prolonged interval, may 
render its site and nature indiscoverable. It will be shown 
later, when surgical repair is reached, that lost tissue is never 
replaced in kind; the new tissue is only a bond of union, struc- 
turally and functionally unlike that which was lost. There is 
a difference between traumatic and pathological loss that must 
be borne in mind. In traumatism there is no antecedent mor- 
bid action, functional or organic. The injury at once destroys 
tissues, and repair is soon set up as a physiological process, a 
sort of exaggeration of normal repair. In pathological condi- 
tions, on the other hand, there has been a longer or shorter 
period of destruction going on. and when this is arrested, 
either by art or spontaneously, repair must be halting and 
imperfect, from the impairment of all function by the preced- 
ing morbid action. 

Now this replacement of lost tissue by tissue of lower grade. 
and unfitted for the former function, destnyrs the organ, more 
or less, or, if any essential organs are involved, the organism 
itself perishes. 



INTRODUCTION 7 

Thus a morbid action in the kidney, that destroys the proper 
tissue by displacement with a new tissue, must necessarily 
destroy the organ, and the organism thereby be deprived of 
an essential factor to its well-being. The consequences are 
practically the same in destructive or degenerative morbid 
action. A heart which has become fatty, has lost its ability to 
carry on its function, just as surely as though its muscular 
elements had been displaced by scirrhus, or lost by suppura- 
tion, or gangrene. 

It must be apparent, and no argument can possibly be 
required to enforce it — that a morbid action once set up, the 
vis medicatrix naiurce about which so much was formerly said, 
can do little to arrest,- and as little to repair. The new tissue 
exists under the same conditions that the normal tissue did. 
The destroyed tissue, can only be imperfectly replaced. The 
degenerated tissue cannot be made over; it must remain 
unchanged and thus cripple the part, or undergo destruction. 
The sole function of the vis medicatrix must necessarily be to 
protect the organism from the assaults of morbid action, to 
oppose its extension when once operative, or to repair, as far 
as possible, such damage as may be done. The repair, we 
shall see in a later chapter, is never reproduction; it is never 
more than a compromise. The local and structural defect must 
operate as a functional weakness, and future morbid action 
is more readily set up. The lesion leaves a scar that remains 
during life. 

It must be remembered, that "nature" does not reproduce 
lost structures; it simply fills the gap with a bond of union. 
It may be truly said that " nature" is a bad physician; it never 
cured a morbid action without doing as much damage, or 
more, than the disease did. It will remove foreign bodies by 
a destructive suppuration and overcome any impediment to 
function, or attempt to do so, by destroying the organ at 
fault. Illustrations are too numerous to need mention. The 
function of the vis medicatrix being to protect the organism 
from morbid influences, when disease comes "nature" has 
exhausted its resources and the existence of disease is a con- 
ession of defeat. 



S ELEMENTS OF SURGICAL PATHOLOGY 

One other fact as to classification. Morbid action is either 
specific or non-specific. The terms are often used very loosely, 
and fail, frequently, to convey a definite meaning. Among 
medical students I have always found it quite difficult to disa- 
buse their minds of a pre-conception, that specific is another 
term for syphilis. It is true that syphilis is eminently specific, 
indeed may well stand as a t} T pe of the whole class, but of 
course it is very far from being the only representative of such 
forms of disease. There are certain characters that attach to 
specificity; all of them must be present in any given case. It 
will be better perhaps to put these characteristics in the follow- 
ing form: 

i. There must be an unvarying natural history; one case 
must be just like another, only differing in degree, or viru- 
lency. 

2. There must be a regular progression of phenomena. 
Thus : 

A period of incubation ; 
A period of efflorescence; 
A period of decline. 

3. There must be a series of sequela?, as distinguished 
from concomitants, or complications. 

4. The products of the morbid action must be contagious; 
they must be capable of conve}~ing the infection to others. 

5. The contagious principle must be hetero-inoculable, 
that is, inocuous to the individual furnishing them. 

6. There must be future immunity, prophylaxis. 

Should any of this sextette be wanting, the case cannot be 
considered typically specific. 

A non-specific disease is the opposite of all this; some one or 
more of the elements must be lacking. While it is impossible 
to state that any one of the six is of higher rank or importance 
than another, possibly the future immunity and hetero-inocu- 
lability of the products might stand as the characters that 
render a specific disease something radically different from 
those in which these features are lacking. It is somewhat 
singular, when we consider that the microbian theory of causa- 



[NTRODUCTION 9 

tion would make it peculiarly applicable to specific diseases, 
vet it is in the two notably specific forms, viz.: small-pox and 
syphilis, that no such causation has been demonstrated to the 
satisfaction of the profession. 

So much for my conception of the nature of morbid action. 
It must surely be admitted that the facts are quite as stated, 
however much discussion there may be about the cause for 
the condition. Any theory of therapeutics that is not based 
on some tenable theory of morbid action must, in the nature of 
things, lack something of a scientific foundation. When a 
theory of morbid action gives support to a theory of therapeu- 
ticSj and the practical application gives the expected and 
desired results, surely there is good ground for the belief that 
theory has become fact. 

Before taking up the more particular study of Surgical 
Pathology, there are two preliminary questions that should be 
answered, if possible. The first of these is: what is Surgery? 
On careless or superficial examination, the question would 
seem to be one easily answered, but such is far from being 
the case. One class of practitioners connect the word with its 
ancient significance, and restrict its use to conditions that may 
or do call for purely mechanical or instrumental treatment. If 
this were true, it would not be long ere surgery would include 
only accidents, deformities, or defects possible of alleviation by 
art. Another class would make it include all morbid conditions 
that are characterized by objective phenomena. This would 
give such a wide range, in these days of diagnostic •• instru- 
ments of precision,*' that the physician, as distinct from the 
surgeon, would find himself left with a very limited and nar- 
row held, and one that would grow even smaller year by year. 
Neither of these definitions, therefore, can be considered sat- 
isfactory, albeit each of them possesses a part of the truth. 
The strict application of the word, in accordance with modern 
practice, would put under the head of surgical affections all 
morbid action, resulting in radical tissue-change, whether 
degenerative or constructive (chiefly the latter), occurring on 
the surface of the body, or accessible inner parts, together 



IO ELEMENTS OF SURGICAL PATHOLOGY 

with deformities, acquired or inherited, and accidents of all 
kinds. Thus while lithiasis, when confined to the kidney, is a 
purely medical affair, stone in the bladder, on the contrary, is 
as eminently surgical. The nucleus from the vesical stone 
may be derived from the kidney, however, and if, at its first 
formation, its fate and destiny could be foreseen, the renal 
lithiasis would be surgical and not medical. Inasmuch as a_ 
large proportion of vesical calculi do originate in deeper por- 
tions of the urinary tract, urinary lithiasis is commonly classed 
among the properly surgical affections. It would seem, there- 
fore, that a categorical answer to the query cannot be made,, 
at least in the present state of the science; the classification of 
morbid conditions, into medical or surgical, is purely arbitrary 
and cannot be otherwise; custom and an indefinite standard 
have made a classification that is quite generally accepted, and 
with that we must at present be content. This refers, of 
course, to conditions of the body in which no question of 
mechanical or instrumental treatment has admission; in others 
there is no debate. 

This second question is: What is Pathology? Fortunately 
this can be more readily and definitely answered, nevertheless 
there would seem to be a few 7 who entertain views and opin- 
ions very wide of the truth. The etymology of the word 
sufficiently defines the ground to be covered, that is "a dis- 
course on suffering" or disease. Thus we find that pathology 
is literally the natural history of morbid action, including 
objectivity; etiology, remote and immediate; character of the 
leision, constructive or destructive; as well as furnishing data 
to trace to their source all purely subjective phenomena, esti- 
mate their value, and determine their significance. Therapeu- 
tics has, as already noted, the closest relationship to pathology* 
if one would escape becoming a mere routinist, and experi- 
mentalist; and the prognosis is something unattainable, if the 
study of the fundamental principles of morbid action is ignored. 
Even morbid anatomy, which some consider the whole of 
pathology, has a significance to the scientist, which seems to be 
entirely unsuspected by a respectable minority in our branch 
of the therapeutic art. 



[NTRODUCTION n 

The fundamental ideas, in the discussion of the various exhi- 
bitions of morbid action that will claim attention in the following 
pages, will be that bodily health is dependent upon normality 
of function; that function is directly related to structural integ- 
rity. That modifications of function are the result of morbid 
influences not necessarily material in character. Finally, that 
sufficient explanation of all the phenomena is to be found in 
accepted facts of physiology and chemistry. 



I.— DIAGNOSIS 

Diagnosis is a term signifying the formation of a theory of 
a given case, not so much with reference to giving it a name 
as to comprehend its natural history. A diagnosis is reached 
in many ways; sometimes prolonged and frequently repeated 
examinations will be necessary; at other times a conclusion 
can be reached very quickly, often at a mere glance. Inas- 
much as a correct theory of a case has relation to prognosis 
as well as therapeutics, none can afford to slight or neglect it, 
albeit there are a few who affect to treat it as of little 
moment. Wherever examination of any extent is needed to 
make out a diagnosis, the order of procedure must be by one 
of two methods, analysis, otherwise called "exclusion" — or 
synthesis, which might be called "inclusion." Unquestionably 
the former is to be preferred, but inasmuch as cases may arise 
in which a choice of methods is not presented, a word or two, 
if only for illustration, may be needed. 

Analytical Diagnosis is a process of differentiation, in 
which the features of a given case that are common to many 
forms of morbid action are selected, and the exclusion of those 
not present. As a case in point, a tumor on the head is pre- 
sented. It may be a sebaceous cyst, a fungus of the cranium, 
fungus of the dura-mater, enostosis, or hernia cerebri. It is 
noticed that there are no signs of brain lesion, either past or 
present, no history of traumatism; a slow growth and absence 
of pain. At once hernia cerebri and fungus of the dura- 
mater are excluded. The tumor is soft and movable, and exos- 
tosis is stricken out. It is symmetrical in shape, movable at 
the base, and hairless; also the growth has been slow, and 



ANAMNESIS 13 

there are probably more than one. This excludes fungus of 
the cranium, and leaves sebaceous cyst alone. In the great 
majority of cases this would be a natural process, one that 
reaches the information desired in the quickest manner, and 
by the most direct route. To some extent it represents the 
manner in which the remedy is selected by the majority of 
Homoeopaths. 

Synthetical Diagnosis, or the method of "inclusion," is 
occasionally practiced, though I fancy it is nearly always a 
question of necessity rather than of choice. In this case the 
mind of the examiner is a blank; he forms no conception of 
the case in advance, and is compelled to construct one as the 
narrative or examination proceeds. In some forms of the neu- 
roses, in hysteria, in feigned diseases, or possibly where the 
patient is unconscious or insane, the synthetic method may be 
the only practicable one. There are a small class of cases in 
which the subjectivity constitutes the whole of the case, but 
they are very few in number; it is the exceptional case when 
there is no objectivity, if only posture, facial expression, or the 
like. 

However the diagnosis is reached, it is based upon three 
factors : Anamnesis (history) , near or remote ; Etiology (caus- 
ation), essential and accidental; and Semeiology (symptoms), 
all the accompanying phenomena. 

ANAMNESIS. 

In one sense the history of a case is of the first importance; 
in another it is of minor value, in fact may be misleading. 
Truthfully told, it is, very often, our only guide to a correct 
diagnosis. There are so many causes for error, however, 
some of them involuntary, and others designed,[that it is a safe 
rule to give no value to statements that are not borne out by 
the semeiology, particularly the objectivity. From mercenary 
motives, to extort charity; or to excite sympathy, from ego- 
tism; from fear of punishment, or loss of esteem; from shame, 
when moral delinquencies are in question ; or for various other 
reasons, patients are not seldom untruthful. Some most 



j 4 ELEMENTS OF SURGICAL PATHOLOGY 

remarkable instances have been met; cases in which truthful- 
ness is necessary for the saving of life, patients have not only 
concealed dangerous symptoms, but even denied their exist- 
ence. Women have been known to deny the existence of 
pregnancy, when at the very time the child has been born 
and still attached to the mother and violent haemorrhage is 
endangering their existence. There are many cases in which 
deception is unintentional, as through ignorance, failure to 
understand questions, insanity, or some acute dementia. The 
patient may be unconscious, and the bystanders may not be 
able or willing to give an}' information. Thus there are very 
many conditions that often render a history of no value, or 
impossible to obtain, and other means are to be taken to secure 
the information. These difficulties are sufficiently embarrass- 
ing when immediate history is needed, as in acute affections, 
and accidental surgery; they become more serious, perhaps, in 
cases where remote history, as in chronic cases, is required, 
particularly as to ancestry. 

Anamnesis includes several considerations, particularly in old 
chronic cases or some infantile affections. Thus previous his- 
tory is at times something almost indispensable to a correct 
diagnosis, in some of the exanthemata, alopecia, bone diseases, 
glandular enlargements, or affections of the eye, where syph- 
ilis may be suspected. The initial lesion of syphilis is often so 
insignificant that it escapes detection and thus, unintentionally, 
an important fact is concealed; or some other motive may 
prompt a patient to deny such an occurrence, notwithstanding 
he knows the contrary. Even in accidents, fractures, disloca- 
tions and gun-shot o\' other wounds, the conditions under which 
the accident occurred, will often constitute very essential feat- 
ures. A fracture near a joint, or extending into one, often 
presents so many s}'mptoms of dislocation, that an accurate 
diagnosis is well-nigh impossible. In such cases, knowledge 
of how the accident was received may often turn the scale 
in one or the other direction. In fact there are few surgical 
affections or conditions in which a truthful and circumstantia 
history is not of the first importance, for purposes of diagnosis 



ETIOLOGY 15 

and vet the sources of error are so numerous that something- 
additional and confirmatory must always be sought. 

Another item in this connection, is duration of the -present 
conditio)!. In specific diseases, and some of those that are 
called " self-limiting," an obscure diagnosis may be cleared by 
learning how long a time has elapsed since the first symptoms 
appeared. This fact is of more value for purposes of prog- 
nosis, it is true, but is not without value in diagnosis as well. 
As an illustration, take a dislocation of the shoulder. The 
time that has elapsed determines the condition of the parts 
involved, whether original parts are obliterated or not; the 
condition of muscles, nerves, or blood vessels as to shortening 
or the establishment of new relations, — in a word, whether 
the dislocation remains recent, or has become ancient. 

Course and Development, from the commencement to the 
time of examination, is of similar value. The regular pro- 
gression of successive phenomena, as occurs in venereal spe- 
cific affections; the sudden rise in temperature, and associ- 
ated symptoms on the fourth or fifth day after injury or oper- 
ation, as indicative of septic affection; the general formation 
of adhesions and glandular enlargements, occurring in malig- 
nant growths, are all cases in point of the value of accurate 
history in this respect. A truthful and minute history in all 
the above particulars would alone be amply sufficient to form 
a diagnosis; but as such is never,, or rarely, to be had, we 
must go farther in our examination, to fill gaps in the record, 
and to confirm what has been presented. 

ETIOLOGY 

The causes of disease or injury must necessarily play a 
most important part in diagnosis, taking equal rank and liable 
to the same limitations as history. In nearly all cases the first 
step is to separate alleged from actual causation. In a large 
number of cases, perhaps a majority in surgical practice, mor- 
bid conditions are referred to some accident or injury. The 
usual course of events in traumatism is for the injured tissues 
to speedily return to something near their former state. 



1 6 ELEMENTS OF SURGICAL PATHOLOGY 

Occasionally important structures are divided, such as muscles 
or nerves, and a loss of function ensues; this loss is immediate 
and permanent, but later changes frequently occur, resulting 
in some secondary or remote loss. Where the traumatism is 
not sufficiently severe to produce extensive loss of structure, 
the consequences are always evanescent. Later consequences 
in the nature of morbid action are rare. When such a con- 
nection is made out, in the majority of cases there can be no 
question, the morbid action was roused into activity by the 
traumatism, which latter has, therefore, only an accidental 
relation to the former. Morbid action can only arise from 
traumatism, pure and simple, when the accident so modifies 
nutrition that trophic or degenerative processes are set up. 
As a stimulus to arouse a latent morbid action into activity, 
traumatism unquestionably plays a very important part. It is 
equally true that the degree of injury is usually very slight; 
anything that will induce local irritation. We must look else- 
where, then, for the actual causes for morbid action, and may 
classify them under two heads, the mate rial and the immaterial. 

Material Causative factors, including mechanical injuries 
of all kinds, unquestionably play a most important part. 
While not a natural arrangement, chemical agencies must also 
be included under this head. For some years past the micro- 
bian origin of morbid action has been an article of faith to a 
large majority of the medical profession, and is still so to some 
"extent, but the original teaching has been so modified that it 
looks as though the whole question was on the eve of retire- 
ment to the limbo of medical curiosities. It is not proposed to 
argue the question at any length, but something must be said, 
if for no other reason, to justify the teaching to follow later, so 
radically different from that popular to-day. 

The objections to the doctrine of bacterial infection are 
many. One of the most potent, it seems to me, is the insuffi- 
ciency of the philosophy. To make the statements or argu- 
ments of the bacteriologists authoritative, two things are 
necessary: First, an unfailing occurrence of a definite form 
of morbid action when a particular organism is present. Sec- 



ETIOLOGY 17 

ttdj the organism must always be present when the disease is 
encountered. To this might well be added another, viz., the 
presence of organisms must antedate the symptoms of disease. 
All of these conditions are wanting at times; frequently one of 
them is lacking, and it would seem a failure in any one of 
these particulars must be fatal to the theory, and the whole 
system of philosophy based thereon. It is admitted that the 
last, or the appearanee of microbes before the outbreak of 
disease, is difficult to establish, or the reverse, as medical 
attention is rarely directed to a patient before he becomes 
sick. We do know, if we may believe the evidence of our 
senses, that there are many cases in which no organisms are 
found where the teaching of the day renders it essential that 
they should be. A notable illustration is found in suppuration, 
where there are certain forms that seem to be sterile, and in 
others the streptococcus is found in abundance. There are 
other diseases, like small-pox and syphilis, the most virulent 
ok the specific contagia. where either no supposed pathogenic 
organisms have been found at all, or the evidence is so con- 
flicting that it is a matter of grave doubt. 

In the American Medico-Surgical Bulletin, for May, 1S95. 
the following language is used in an editorial article on •• Anti- 
toxine-Therapy," which is significant in this connection: 

; - Studying the subject from the one side or the other alone is 
sure to lead the investigator into error. If the bacteriological 
side only is considered, the results are bound to be misleading. 
For it is a well-known fact that quite a large percentage of 
cases is known to have the Klebs-Loeffler bacilli in the mouth 
and fauces and still never have diphtheria, nor cause the dis- 
ease in other subjects, so far as can be directly determined. 
If all these cases are to be classed as diphtheria and subjected 
to the antitoxine treatment in the absence of well-marked 
clinical evidence of the disease, which appears to be the plan 
pursued in many instances, the mortality will naturally fall. 
and a very fine showing can be made for the antitoxine- 
therapy. 

•• On the other hand, it is equally w r ell known that the most 



l8 ELEMENTS OF SURGICAL PATHOLOGY 

competent clinicians and bacteriologists admit that in fully 25 
per cent, of the cases of true diphtheria the Klebs-Loeffler 
bacillus cannot be found, and that of these a large percentage 
of the cases dies. If this group in which the bacilli cannot be 
found is not subjected to the antitoxine treatment, and is 
excluded from the mortality statistics of diphtheria, another 
large source of error in the making up of the statistics is 
apparent. In this particular class the death rate may run high, 
even with the aid of the antitoxine treatment. Until the mor- 
tality of this group is added to the bacterial class, and the 
cases which have simply the Klebs-Loeffler bacilli in the 
throat, but are without symptoms, have been eliminated from 
the statistics, no reliable statistics can be developed as to the 
true value of the antitoxine treatment in reducing the raor- ■ 
tality in diphtheria." 

Of course the occasional failure of all the conditions must 
necessarily destroy the philosophy, but even were it not so 
there are other reasons that should p;o to show its insufficiency. 
The first of these seems to be that the specific forms of the 
so-called pathogenetic organisms are not sufficient in variety to 
furnish such marked variety in the forms of morbid action. 
What is known as -pho-morfihism, in which bacterial forms go 
through a cycle of changes, is an apparently fatal blow 7 to the 
theory that morphology and physical properties are satisfac- 
tory guides in determining the species. Thus the editor of 
Fellow t s' Monographs (Part xi, 1st Sect., p. 45), says: "As 
to the question of pleomorphism do the various micro- 
organisms which exhibit different morphological and physiolog- 
ical attributes, belong to different species? or do these germs 
pass through curious adaptive stages, dependent on their devel- 
opment and environment? Pasteur himself, as one can see 
in his work on 'Studies on Fermentation,' is most careful not to 
dogmatize on this matter, but rather to take up the 'not 
proven' attitude; others, like Koch, have pronounced decidedly 
against the pleomorphism. But certainly the w T eight of evi- 
dence is increasing daily and appears in many instances to have 
taken the form of demonstration, that, if w r e want the clearest 



ETIOLOGY 



J 9 



proof of an influence of nutritive media and of external circum- 
stances in altering old, and developing new species, we have 
it in micro-bacteria; and that micrococcus, bacterium, leptotkrix, 

and spirilum. are but different phases of development of 
♦ micrococcus' which is the primitive form." Now if species 
and form go for nothing in determining properties or function, 
to sav nothing of the usefulness of "bacteriology" for diagnos- 
tic purposes, all relationship to causation must cease. It is 
impossible to conceive of the same cause at one time furnish- 
ing cholera, and another anthrax, and still another suppuration. 
The experiments of Petenkoffer and Ehrlich, with the com- 
ma bacillus, have given a shock to the doctrine which must go 
far to hasten its extinction, or at least to cause an entire revolu- 
tion. That many forms of morbid action are accompanied by 
various species of micro-organisms, none can question. Ad- 
mitting, for argument only, that they are always present, and 
when present definite morbid phenomena occur, it is jumping 
at a conclusion to claim them as causes. Is there not equally 
good evidence to prove a compensating function ? May thev 
not be considered curative rather than causative f Again, it 
morbid action is to be explained by bacterial contact, all such 
forms must be contagious, or infectious, or specific, or all three. 
There is one way in which bacterial infection may, and prob- 
ably does produce morbid action; that is by their dead bodies 
setting up septicaemia. Many writers, notably in the current 
volume of the International Journal of Surgery (1893), have 
strenuously insisted that the use of antiseptic dressings have 
■produced septic infection, and probably in this way, viz. destroy- 
ing the micro-organisms in the wound. Of course such a 
practice may devitalize the tissues, and thus furnish septic 
material. Thus J. McFadden Gaston, M. D., of Atlanta, 
Ga.. in a paper read before the Medical Association of Georgia. 
April 19th, 1893 [International Journal of Surgery, Vol. vi., 
p. 129), says: "The modes adopted for testing the introduc- 
tion of microbes into the system, have not afforded any con- 
clusive evidence as to the etiological factor in the development 
of morbid products. But the observation of bacteriologists has 
C 2 



20 ELEMENTS OF SURGICAL PATHOLOGY 

gone very far towards establishing the existence of special 
forms of bacilli in different types of disease. Whether these 
various modifications of the bacterial order enter as a causative 
element; or simply as a concomitant of the several disorders 
with which they are associated, has not been satisfactorily 
elucidated A grave point for consideration in connec- 
tion with the development of bacteria in the physical organiza- 
tion, is whether they are hurtful in the living condition or after 
losing their vitality and acting as ptomaines in the organs. If 
the analogy of the growth and the decay of hydatids in the 
tissues can hold in the case of bacteria, it may be infered that 
the chief harm results from their death and decomposition." 

Furthermore, the bacterial theory is unnecessary, in so far as 
there is an ample, logical and, it seems to me, self-evident 
explanation of the occurrence of disease without their aid. 
Disease is nothing but a perversion of function, disturbance of 
nutrition; in other words it is what is expressed in the term 
"morbid action." Of course this statement goes for nothing 
as an argument, for because a thing can be done one way is no 
good reason for not doing it in another. Neither can it be 
overlooked, that the morbid action may as well receive its ini- 
tiation from bacterial infection, as any other external agency. 
But the fact remains that the beginnings of bacteriology were 
based upon the assumption that the causes for morbid action 
were inexplicable and that this new philosophy furnished 
knowledge that had hitherto been unattainable. On these 
grounds, I base the objection of unsatisfactoriness, nay more, 
that the difficulty, if there was one, has only been added to. 
It is an explanation that fails to explain. It is unsatisfactory, 
also, on the ground that infection or contact is, by their own 
confession, far from being followed invariably by the charac- 
teristic morbid action. If the anthrax germ is the cause for 
anthrax, no one should escape who is brought within its sphere 
of influence. But multitudes do escape, possibly the majority. 
Why? They tell us there must be a receptivity, a suitable 
soil, a predisposition, a derangement of function. No one dis- 
putes this, but if the commencement or predisposition to illness 



ETIOLOGY 21 

must exist before the germ contact occurs, it is a bold man who 
affirms the germ was the cause for all the later mischief. 

Again, 1 rind the claims of the bacteriologists unscientific. 
If want of accuracy in foundation principles, and insufficiency 
of the theory to account for the phenomena is granted, lack in 
scientific requirements is a necessary consequence. The 
presence of micro-organisms in man}- cases of disease is 
granted, but their relationship thereto is not unquestioned. 
There are equally good reasons to esteem them conservators, 
or consequences as active and specific causative agents. But 
there is one circumstance that weighs heavily in the scale 
against the bacteriologist, viz., that nothing of therapeutic value 
has come out of the discussion. At first we were to destroy 
them in the wound, and apply dressings that would prevent 
later access. Then we were to destroy them in the atmos- 
phere, in addition to the wound treatment. Then it was found 
the germicide agents did about as much harm, or more, to the 
tissues and the organism, as the germs. Then that the oper- 
ator's health suffered from the germicides; and now, once in 
a while, we meet with men who have the courage of their 
convictions, and tell us to avoid bringing any chemicals in 
contact with a wound, and even to avoid plain and sterilized 
water as lowering the vitality and resistance of tissues. 
Who would dare, five years ago, or even two, to use such 
language as that of Dr. Gaston (/. c), who says: "At this 
time the medical profession is undergoing a most interesting 
transition from the extreme views which have been held by 
some in regard to the employment of germicides in surgical 
practice. There was a time within the past decade when it 
was deemed to be scientific and progressive to use antiseptic 
measures of the most energetic kind in all operations whether 
there was a septic element to combat or not. But thanks to 
the mature investigation of the effects of germicides upon 
normal structures, by bacteriologists of the highest order of 
qualifications for this class of work, it has been demonstrated 
that these so-called antiseptic agents are capable of setting up 
septic processes in healthy tissues. The tables are now 



2 2 ELEMENTS OF SURGICAL PATHOLOGY 

turned, and instead of a surgeon being compromised by elim- 
inating germicides from his surgical procedures in ordinary 
cases, and confining his irrigation of recent wounds to simple 
sterilized water, it is he who departs from this course by the 
employment of solutions impregnated with toxic agents, who 
is held responsible for the consequences of their absorption." 
Those who practice what they now call i; aseptic " surgery 
are very contradictor}' in their statements. At one time they 
tell us the germs find entrance through the wound, and when 
sepsis or suppuration occurs we can usually find some error in 
the dressings to account for it. At another time, however, 
we are told the microbes enter the organism by other chan- 
nels, and find their way to the injured territory through the 
blood. Undoubtedly we find many kinds of micro-organisms 
in the tissues, and possibly in the blood, in cases where there 
were no wounds to give them entrance. How is exclusion to 
be practiced, when all the efforts are expended on the dress- 
ing of the wounds and such accessible routes left open as the 
mouth, nose, and other outlets? In short, after a patient, 
long-lasting, and serious study of the question of bacterial 
infection, particularly as causative of disease, observation of 
the practice and results of those who adhere to it most strictly. 
and a very careful study of wound treatment in my own prac- 
tice and of those who think with me. I am forced to the con- 
clusion that the whole theory is a false one. One thing is 
absolutely certain, that years of experimentation have con- 
clusively demonstrated, that practice in accordance with the 
teachings of bacteriology has given either negative or disas- 
trous results. 

Immaterial Causation, by which is to be understood the 
appearance of disease without visible connection with external 
morbific agencies, is represented in a large class of cases. If 
the theory adopted as to causation in general is true, anything 
which would derange function, even for a very short time, or 
in a minor degree, is capable of setting up morbid action; 
-provided there is a predisposition thereto, or the irritant is 
supplied sufficiently often. Thus, it is found that not only pure 



ETIOLOGY 23 

neuroses, but conditions characterized by the most extensive 
tissue-change, may result from mental disturbances alone. 
Fright, and possibly joy, under certain conditions of the body, 
may even cause death. It is supposed by many that despond- 
ent states of the mind may be an essential predisponent to 
carcinoma. However the facts may be with reference to the 
grosser lesions, there can be no doubt that what ma}' be 
called purely 'psychical conditions may be the cause for pro- 
found organic disturbance, and with other conditions favorable 
ink lesions are possible. 

Now, as to this part of our subject it may be said, and with 
the authority of dogma, that no matter what the character of 
the morbid action may be, there must be, in all cases, an 
organic lesion. This lesion may be macroscopic or micro- 
scopic, gross or minute, but the statement must be accepted 
that while perfection of structure generally insures correspond- 
ingly perfect function, there can be no loss or disturbance of 
function without an antecedent structural loss. 

Finally, as to Etiology, it serves a useful and practical pur- 
pose to classifv ail causative factors under two heads, the pre- 
disposing- and the exciting'. 

Predisposing - causes are those conditions that render one 
person more liable to morbid action or injury than another. 
From the fact that such conditions are of a character to 
retard or prejudice repair or recovery? they are also spoken 
of as maintaining-. Also, from a consideration of these two 
circumstances, such factors must be of the utmost importance; 
they are spoken of as essential. There can be no question 
that this class of causes is of the utmost importance, not only 
for purposes of diagnosis, but for therapeutics as well. Neces- 
sarily, they are causes of very great variety, including some 
that are constant, and others that are occasional, but all hav- 
ing a strictly personal character. Thus Age, Sex, Occupa- 
tion, Social conditions, Race, Habits, Previous diseases, and 
Family history are all to be considered. 

Age, by alterations in the bones, both as to form and com- 
position, is an important factor in differentiating fracture from 



24 ELEMENTS OF SURGICAL PATHOLOGY 

dislocation. The alterations in function, due to old age; the 
slowness of repair, the predisposition to certain morbid condi- 
tions, as carcinoma, will often serve to clear up a doubtful diag- 
nosis. For instance, a tumor may have certain characters that 
render it difficult to determine whether it be sarcoma or car- 
cinoma, but if it be on a young person the presumption is 
strong in favor of sarcoma. 

Sex is. of course, important in the diagnosis of abdominal 
tumors. Apart from this, the exigencies of child-birth, the 
monthly functional disturbances often accompanying menstru- 
ation, and lactation, render women as a class more liable to 
morbid action than men. 

Occupation is little less important than age or sex. not onlv 
with liability to injury but various diseases. As a rule men are 
more exposed to accident than women, and also, from their 
active business life are predisposed to derangements of the 
stomach and bowels. Certain callings are notably dangerous 
to health ; as illustrations, the necrosis of match-makers, from 
the action of phosphorus; the affections of the lungs among 
grinders in steel-works: of rheumatism, among millwrights, or 
those who work in water, may be noted. 

Social Condition, with particular reference to worldly con- 
dition, is another important item. The idle wealthy, and the 
over-worked poor, alike furnish susceptibility to particular 
forms of disease. The clothing, lodging, and food must exer- 
cise a very important influence in the liability to disease, and 
such considerations are often closely related to social condition. 
In the same connection the question "married or single" will 
be an important factor, particularly as to presumption of 
pregnancy. 

Race has more or less to do with liability or susceptibility 
to morbid action, partly from environment, and partly from 
habits of body perpetuated from generation to generation until 
• they assume permanent characters. Goitre, among the Alpine 
Swiss; aneurysm among the Irish and North of Europe peo- 
ple; urinary calculus in certain localities, are instances in point. 
There are certain forms of disease, or abnormalties, such as 



ETIOLOGY 



25 



hernia, that seem to be unknown among certain races, but it i.s 
probable, in this case at least, that it is more a question of 
habit. A very important consideration, under this head, but 
unfortunately one that is not well understood — is tolerance of 
mutilation. The German seems to be the least tolerant, and 
the Chinese the most so. Xo attempt has been made to 
account for this remarkable difference, at least nothing conclu- 
sive has been established. The fact remains, however, and is 
one of much practical interest. 

Habits naturally exercise a most potent influence on predis- 
position. Addiction to alcohol, sexual excesses, or over-use of 
any organ or function, will frequently result in morbid action- 
In this instance not only will the elicitation of this fact throw 
light on the diagnosis, but will point to important considera- 
tions in therapeutics. Habits and' race must, to some extent, 
be considered together; many habits are peculiar, or more 
persistent among a race of people, and the consequences are of 
course soon recognized as peculiar to them, or very common 
among them. 

Previous Diseases must be considered, more particularly 
to establish a fact of sequence. Thus a history of the initial 
lesion of syphilis would clear up a diagnosis in some eye dis- 
eases, or exanthemata, or bone conditions. Then rheumatism, 
as a case in point in another direction, might account for some 
heart lesion. In these cases prognosis is much more con- 
cerned than therapeutics, and yet treatment may sometimes 
be anticipating when sequelae are recognized. 

Family History has a certain value, though not as much as 
was at one time attached to it. Offspring certainly may inherit 
••weak tissues," or predisposition to disease, and again prophy- 
laxis may be secured, or at all events attempted, if certain facts 
are known. 

Exciting Causes are those that operate on all persons alike, 
the consequences being the same under all similar conditions, 
varying only in degree, which is determined by the predispo- 
sition of the individual, or variations in the intensity of the vul- 
nerating force, or similar modification. Sometimes the terms 



26 ELEMENTS OF SURGICAL PATHOLOGY 

"determining" or "accidental" are used. The question must 
be considered from two points of view, with reference to 
traumatism, or a purely morbid state. 

As to traumatism, the question is important in locating a 
lesion: as in stab-wounds, and gun-shot injuries of cavities. 
Also, at times, with reference to particular vessels or nerves. 
It is also useful in differentiating fractures and dislocations, a 
bending force oftener producing the former, and a twisting the 
latter. In many other ways it often becomes important to 
determine how and under what circumstances an injury was 
received, Even in cases where fracture is easily made out, it 
is of the utmost importance, very frequently, to know whether 
the force was applied directly or indirectly, the line of fracture 
and the associated injury, if any, being often determinable 
thereby- But all this simply relates to injuries and the state 
of the parts as resulting therefrom. When any distinct form 
of morbid action is present, other questions arise. For in- 
stance: A small lesion results in erysipelas, suppuration, ulcer- 
ation, gangrene, or a tumor. Now what relation did the injury 
sustain to the latter phenomena? Surely not causative, in the 
proper sense, as there was nothing in the nature of the alleged 
cause to produce such consequences. They come either from 
causes operating within the organism (predisposing), or infec- 
tion of some kind, coming from without, the injury simply 
furnishing a mode of entrance, in the one case, or arousing a 
latent morbid process in the other. In this sense all exciting 
causes must be accidental. They are only determining in the 
case of pure traumatism. Where morbid action follows, it can 
only come from a cause capable of inducing that particular 
form and no other. Erysipelas and ordinary suppuration are 
not one and the same thing, nor are they related to each other. 
So the terms "exciting," "determining," and "accidental," are 
not, strictly speaking, convertible terms. They all belong to 
a common class, but are not identical. 

Grouping all the exciting causes together, they may be 
classified as traumatic, exposure to contagion, or exposure to 
morbid influences. 

Traumatism or the receipt of injury, can never be consid- 



ETIOLOGY 27 

ered a cause for morbid action, and yet loss of blood, confine- 
ment, and shock will produce functional disturbance which 
may result in disease. A healthy body, as will be shown 
later — when injured, immediately sets about repair, by a sort 
of exaggeration of physiological processes. If they go wrong, 
are too energetic, or a secondary disturbing factor comes in, 
morbid action may result. Perhaps the commonest of these 
secondary factors is septic absorption, from the decomp- 
sition of devitalized tissues. Deformity, or loss of parts 
(functionally) from adhesions, division, and the like, are not to 
be considered "morbid." With these limitations we may say, 
and say truthfully, that mere traumatism cannot originate 
morbid action. Disease may follow, but only from the opera- 
tion of secondary forces, often that are made operative, it is 
true, by injury done. 

Exposure to Contagion is something very different from 
the above, and opens up a field for discussion that is almost 
limitless. Of course, it is important to have some conception 
of the nature of contagion, but the testimony offered is so 
conflicting, and the actual knowledge, in the very nature of 
things, so meagre, that it will be long before anything definite 
is obtainable. That certain material is capable of setting up 
morbid action in the body, under suitable conditions, is evi- 
dent. That this material, for the most part, is organic or a 
product of organic bodies, and in some instances is associated, in 
one way or another, with micro-organisms, is indisputable. 
This is true of all the specific diseases, the contagious and 
infectious particularly, and of many of the exanthema. Some 
of the most contagious and specific diseases, as already stated,, 
are not as yet associated with bacteria, or similar organisms, 
and w r hile that may be merely a question of technique, to be 
satisfied in the future, yet we are justified in assuming, in 
view of the long and patient researches that have as yet come 
to nothing, that if micro-organisms are essential factors, these 
conditions must stand as exceptions to the rule. But in some 
way these contagious. elements have certain powers of inocu- 
lation, properties which, for the present, must be largely 
matters of speculation. In many cases the results of such 



2 8 ELEMENTS OF SURGICAL PATHOLOGY 

contact resemble very closely, if they are not identical with, 
septic infection. The microbes may be nothing more than 
media of contagion; or the decomposition they undergo may 
be the active agency; or they may — although there are grave 
doubts about it — be actually specific, or pathogenetic. How- 
ever this may be. not to reopen a discussion closed in an 
earlier chapter, — one thing is evident: mere contact will not 
necessarily result in infection. The individual may be pro- 
tected bv previous inoculation; he may be invulnerable from 
ancestral inoculation; he may not be susceptible to morbid 
influences. As has been tersely stated (the reference has 
been lost), micro-organisms cannot infect a healthy body. 
We seem to know, from numberless experiments, that the 
leucocyte has the property of destroying hostile organisms, 
and from this property has been called "phagocyte." There- 
fore, while exposure to contagion is one of the exciting causes 
of disease, vet the forms of morbid action so set up are few in 
number and there is still needed a predisposition to render 
the contact efficacious. 

Exposure to Morbid Influences has a wider signification 
than the foregoing, including much that is far from being con- 
tagion. The topic, however, can be briefly treated, as the 
conditions are all general in character. They would include 
errors in diet, exposure to cold, deprivation from food, unusual 
fatigue, strong, sudden mental emotions, or any similar or anal- 
ogous emergency that first disturbs function, more or less 
extensively, and then, from some predisposition, sets up mor- 
bid action. It will be shown later that frequent irritation of 
an organ, which is but another term for over use of a function, 
will finally result in some morbid action, and hence, while the 
frequent repetition of an unphysiological activity will fall under 
the head of a predisposing cause (Jiabif), yet it is at the same 
time in the nature of an exciting one. 

SEMEIOLOGY. 

Semeiology, the study of symptoms, is a feature in diag_ 
nosis very different from the other factors discussed. Bv one 



SEMEIOLOGY 



2 9 



class of practitioners very little attention is paid to symptoms, 
at least as to minute differences, and they affect to treat their 
study with disdain. Some of them ridicule the Homoeopath 
because, as they say. --he treats symptoms, and ignores the 
disease."" Possibly such an objector may mean something 
more than the language seems to imply, but it would be inter- 
esting to know by what other means he acquires a knowledge 
of disease. Symptoms are the expression of a morbid action, 
the onlv evidence we have of its existence. Differences in 
similar symptoms point to differences in the morbid process, 
and a diagnosis, to say nothing of treatment, is almost impos- 
sible without giving them due consideration. Another class 
do not attach too much importance to semeiology, because 
that would be impossible, but fail in discrimination. They 
take a partial view of the subject, and neglect to weigh the 
value of indications, or even to verify mere subjectivity. Now, 
all symptoms must fall in one of two classes: essential, or sub- 
ordinate. The former are all such symptoms as may be con- 
sidered central, of paramount value as indices of morbid 
action. To detect them is the aim of the diagnostician, and to 
act on the information furnished the object of the therapeu- 
tist. Hence a symptom must be explained; we must seek to 
know what causes it, as all symptoms are caused by an organic 
lesion. Now. by ••lesion" is not to be understood a visible 
loss of structure or continuity; it is any change in the struc- 
tural characters of a tissue or part, transient or permanent. 
A hyperemia is a lesion in itself, regardless of its duration or 
later consequences. Thus, an essential symptom is that ore, 
or group, which is directly related to the lesion, and is there- 
fore of value to the diagnostician as indicating the seat and 
character of the lesion, and to the therapeutist as furnishing 
most important data for correct treatment. The pathologist 
is also interested, as the natural history of the whole process 
is thus made clear, and prognosis rendered possible. 

Subordinate symptoms are of two kinds: one class are 
those which naturally would follow the particular lesion under 
observation, either by extension of the morbid process, or by 



3o ELEMENTS OF SURGICAL PATHOLOGY 

secondary influences on related functions. The other class are 
those that are determined by idiosyncrasies of the individual, 
and are of minor value as a rule. The value of semeiology, 
as an aid to diagnosis at least, is proportionate to the ability to 
distinguish the central symptom, and separate the essential 
subordinate manifestations from the non-essential. 

All symptoms are to be classified in still another manner: 
subjective and objective. This classification is a fundamental 
one, and must precede the former. 

Subjective symptoms are those which the patient alone can 
appreciate; alterations in feeling and perception that have no 
expression capable of detection, as a rule. Among the more 
important of these is pain, which has no physical expression 
necessarily. In most instances, of course, pain is associated 
with heat, redness, swelling, or something apparent to the 
observer, and yet there are many cases in which there is no 
such expression whatever, nothing but the patient's statement 
in evidence. Other symptoms, such as heat, may be both 
subjective and objective; it is felt by the patient, and can be 
detected by the thermometer. Purely subjective phenomena 
are of little value taken alone, particularly if contradicted by 
objectivity. As a rule, they can be ignored if there is no con- 
firmatory evidence, and at all times must be guardedly ac- 
cepted. The vagaries of hysteria, the ingenuity of malingerers, 
or the lack of intelligent narration by the honest sufferer, com- 
bine to throw a cloud of suspicion around any history of suf- 
fering or disturbed function that is not vouched for by reliable 
objectivity. 

Objective symptoms, on the other hand, are most reliable 
data, depending upon the skill, ability, and experience of the 
observer. They are all such expressions of morbid action as 
can be detected by the physician without the aid of the patient, 
bringing to his aid all the "instruments of precision,*' as the 
microscope, ophthalmoscope, various speculae, chemical analy- 
sis, the thermometer, sphygmograph, and the like. They 
constitute indications of the utmost value and importance, out- 
ranking, possibly, all other elements of diagnosis. Certainly 



SEMEIOLOGY 31 

there are sources of error even here, but they are all, or nearly 
so. personal to the examiner. 

As indications of the class of symptoms coming under this 
head, may be mentioned, information derived from palpation, 
percussion, study of excretions, physiognomy, posture, alter- 
ations in sensation, diminished or preternatural mobility; also 
changes in form, color, volume, transparency, consistency, 
relations, pulsations, sound or smell. Originally this group of 
symptoms included only those that could be seen, felt, heard, 
or smelled by the unaided senses: but the increase in number 
of diagnostic instruments, and their greate'" delicacy, have won- 
derfully enlarged the catalogue. 

By all such means as have been indicated, must the diag- 
nosis in obscure cases be made out. As a matter of course 
experience will greatly shorten the process, but the method is 
practically the same at all times. While neither one of the 
three elements, anamnesis, etiology, and semeiology — -may pos- 
sibly be placed above the other in value, in a large number of 
cases, objective semeiology will unquestionably be of prime 
importance, particularly when the analytical or exclusion 
method is pursued. 



II.— PROGNOSIS 

Prognosis has an intimate relation to diagnosis, inasmuch as 
it is very closely dependent upon it; it is almost impossible, 
under many circumstances, to foretell the result of a case if the 
diagnosis is not clear. The "foretelling." the future history 
of a case is what is meant by prognosis: not only estimating 
the tinal outcome, as to death or recovery, but the course of 
the disease, its possible complications and sequelae, as well as 
the condition, as to usefulness or function, of the parts chiefly 
concerned, cr the whole organism. An accurate prognosis is 
therefore only to be reached through an accurate diagnosis, 
and with more or less experience with similar conditions. 

The natural history of the particular form of morbid action, 
after its recognition, is first to be considered. Under the ordi- 
nary conditions of medical practice, this is always modified in 
many ways. Thus the previous bodily state is of prime 
importance. Almost any morbid condition must, as a matter 
of course, very seriously affect the prognosis: comparatively 
trivial ailments, occurring in one of enfeebled health, or who 
has recently passed through some serious accident, is often a 
portentous affair. This is also true as to accidents, or acute 
surgery. One who has some disease of the bones, will not 
recuperate in a typical manner after fracture: in fact there may 
be no repair at all. Svphilitics. or those who are victims of 
some profound dyscrasia. do not bear injuries well: wounds 
will be slow r to heal, and repair of any kind will be greatly 
prejudiced. 

Of almost, if not quite equal importance, the duration of the 
illness up to the time of commencement of treatment, or since 

32 



PROGNOSIS 33 

the injury had been received, must have a controlling influence 
on the prognosis. While this is true under all forms of dis- 
ease, it is particularly so in eases of accident. Thus a fracture 
that has been neglected until consolidation has commenced, 
may be incapable of reduction, or at least it can only be had 
with difficulty, and then more or less incomplete. So in dislo- 
cations, if the cavity is tilled up, wholly or in part, torn tissues 
united irregularly and with disturbed relations, the prognosis, 
as to recovery of usefulness and symmetry, must be poor. 

The kind of treatment is of the utmost importance as modi- 
fving natural history and qualifying the prognosis. A very 
common occurrence is to meet cases of intestinal obstruction 
that have been treated with violent purgatives, having the 
effect to aggravate the condition — or ignorant attempts at the 
reduction of dislocated joints, converting a simple primary 
dislocation into a complicated secondary one. In homoeopathic 
practice, while medicine is not given in massive or toxic doses, 
many a case is spoiled by a bad prescription. It is a common 
thing for those engaged in special practice, to find their first 
duty to be a correction, if possible, of some improper treat- 
ment. 

Finally, the environment of the patient must receive due 
attention. Exposure to morbid influences must be looked into; 
the clothing of the patient; the sanitary condition of the dwell- 
ing, are all points of first importance. 

Beside all these, circumstances that must modify the natural 
history, and thus obscure the diagnosis, there are others of 
almost equal importance, and yet to some extent included 
in the foregoing. Thus there are various complications that 
may be extrinsic or intrinsic as to origin. With good environ- 
ment, with good treatment, and everything favorable to a suc- 
cessful conduct of a case, some passing indiscretion may set up 
a secondary morbid action, because of the general disturbance 
already existing. Gastralgia, enteritis, cystitis, or some other 
inflammatory affection may thus be superadded to some entirely 
unrelated condition, and even overshadow it entirely. Among 
the extrinsic complications, or rather causes for them, are sec- 

D 



34 ELEMENTS OF SURGICAL PATHOLOGY 

ondary injuries, such as displacement of fragments, or changes 
in the position of the bone in dislocations, from careless or 
awkward moving of the part, or individual. In short the modi- 
fications and complications of diseases, or injuries, by multi- 
tudes of causes, many of them apparently trivial, are so 
many and so various, that there are times when a prognosis 
has to be very guardedly given, or even withheld altogether. 

The problems to be solved in reaching an intelligent prog- 
nosis maybe considered in something like the following order: 
As to continuance of life; as to preservation of function; as to 
the duration of the case; as to the future condition. 

Continuance of Life. — Of course the first thing to be 
settled, on this point, is the part injured, in cases of accident, 
or the natural history of the particular morbid condition, as 
well as the kind of treatment, if any, already instituted, and 
other conditions as noted above. Certain injuries are mortal, 
in the nature of things, such as w r ounds of the medulla or 
upper part of the spinal cord; also wounds of the cardiac 
auricles; or extensive wounds of the liver. Others are mortal 
if not furnished immediate aid, such as wounds of the large 
blood-vessels, as the femoral or carotid, but which m-dj not be 
so if steps are taken immediately to secure the vessels. As to 
morbid action, much depends upon the duration of the case, 
very frequently, which is but another term for the stage 
reached in the development. A notable instance in point is 
carcinoma, in which a cure may be expected if an operation is 
made in a very early stage, but is hopeless, as a rule, in later 
periods. Even in morbid conditions the anatomical question 
must be given precedence very often, as in carcinoma of some 
of the viscera, notably the pancreas, where the morbid action 
extends to the thoracic duct, which is a very common occur- 
rence. One fact must be always borne in mind, however, the 
possibility of recovery in cases of accident that would seem to 
be intrinsically mortal, from some unusual exertion of the vis 
medicatrix naturce, or some fortuitous circumstance altogether 
out of the ordinary course. Thus there are cases of spon- 
taneous cure (painfully few in number) of cancer of the breast 



PROGNOSIS 35 

or other glands, by atrophic changes altogether inexplicable, 
and even extrusion of the growth. In cases of accident, as 
formidable as deeply penetrating wounds of the brain, with 
considerable disorganization of its substance, recovery has 
occasionally been very prompt. In gun-shot, or stab-wounds 
of the heart, there are instances of remarkable endurance, or 
even recovery with no sequelae, or none that were notable- 
Spontaneous arrest of haemorrhage from large vessels; con- 
solidations of enormous aneurysmal tumors, and other for- 
midable conditions, have occurred, infrequently, it is true, but 
sufficientlv often to illustrate the possibility. Thus it can be 
seen that while there are certain morbid conditions that almost 
inevitably lead to death, and some forms of injury that, from a 
consideration of the parts injured and the character of the 
injur}-, would seem to be mortal, yet recovery is possible if not 
probable, and such knowledge should lead one to be guarded 
in prognosis as to continuance of life, unless the indications are 
unmistakable. 

Preservation of Function. — Under this head we find pretty 
much the same considerations as in the foregoing. The con- 
tinuance of function is at all times proportionate to the amount 
or extent of injury done, and this can only be determined by 
the diagnosis, and a knowledge of the manner in which repair 
occurs. It is without doubt true that a lesion of any magni- 
tude is never perfectly repaired; and yet it is equally true that 
after the reparative structure is completed. — that is. after all 
signs of organization have ceased, — there is a slowly-moving 
process of what might be called assimilation going on for the 
rest of the life of the organism, whereby in time the appear- 
ances of injury are gradually lost. But this is only apparent. 
Take, for instance, a muscle that has been completely divided. 
It is evident that as long as the divided parts are kept asunder 
the action of the muscle is lost; the function of the muscle, as 
far as contractility is concerned, is not lost, at least in all cases 
— but there is not the mechanical relationship between the 
origin and insertion that formerly existed. Contraction occurs 
in both directions from the point of division. Now, this gap 

D 2 



36 



ELEMENTS OF SURGICAL PATHOLOGY 



is not filled by muscular fibres, but scar tissue, and the proxi- 
mal portion of the muscle exerts its influence on that, in place 
of the original point of insertion. Possibly, if this should con- 
tinue, the function of the part might not be impaired; the 
effect would simply be that of unduly lengthening a tendon. 
But the scar tissue is inelastic, and is soon drawn out so that 
muscular contraction exerts no influence : the distal part of the 
muscle loses contractility, and undergoing atrophy, likewise 
loses all muscular characters. So again, in this* case, adhe- 
sions may form to the bone, or other near parts, which would 
preserve the proximal portion of the muscle, but the adhesions 
may modify or cripple other functions, or at all events materi- 
ally change the former action of the part. For instance, if the 
biceps cubiti were divided in the lower half, and adhesions 
formed to the humerus, the action of the muscle would be 
very different than when the original insertion into the radius 
was maintained. In the case of nerve lesions similar changes 
occur, possibly the results being more serious. Thus the 
proximal portion would soon, at least in favorable cases, fur- 
nish neural elements that might iu time convert the scar tissue 
into some sort of nervous tissue; but long before this was 
accomplished, the distal portion would be converted into a 
mere fibrous cord, by atrophic processes. The losses of tissue 
from morbid action are similarly repaired, and followed, of 
course, by similar impairment of function, but the destruction 
is not as deep, as a rule, where life is not lost, and loss of func- 
tion is thereby less noticeable. 

Prognosis as to preservation of function must consequently 
depend upon our knowledge of the kind and extent of injury 
done to the tissue, the manner in which the lesion will be 
repaired, and the changed relation of the^arts. 

Duration of the Disease. — It is not at all times easy to 
determine this element in prognosis. In the case of the so- 
called " self -limiting " diseases there are so many disturbing 
influences that have the effect to modify the natural history that 
even here the prognosis must often be guarded. The conjunc- 
tion "if" is a factor of prime importance. If so-and-so does 



PROGNOSIS 37 

not occur, the duration may be foretold with some degree of 
certainty. The chief difficulty, however, is in the case of dis- 
eases that are not self-limited. Here the prognosis is to be 
governed by the intensity of the process, the recuperative 
ability of the patient, and the rapidity of its course, facts which 
may have a different meaning to different observers, equally 
well qualified. Again we find that diagnosis must claim first 
rank; the actual conditions must be recognized, and then the 
knowledge or experience of the observer must determine the 
question of duration. As statistical publications increase, there 
will naturally be more and more certainty in prognosis, but 
the conclusion in any given case must be in accordance with 
the law of averages. 

Future Condition. — In some cases we are promised immu- 
nitv from renewed infection, and yet there are exceptions 
to the rule. In other cases there will be more or less func- 
tional loss, as a rule, and yet accidental occurrences may 
ameliorate or aggravate. In other cases there are certain 
sequelae to be expected; and yet racial peculiarities, inherited 
characters, the occurrence of secondary complications, or 
something unusual in the way of treatment may altogether 
pervert them, or if they do occur, there may be some unusual 
symptoms, some variations from the standard as to order of 
appearance or other character, that the diagnosis itself may be 
brought into question. 

As to prognosis in general, therefore, it will be readily seen 
that nothing can be done without a correct diagnosis, and a 
careful study of causation and semeiology. To this must be 
added personal experience. When all the prerequisites are 
duly furnished, there are even then elements of uncertainty 
that must, in the nature of things, stand in the way of any- 
thing approaching certainty. It is far easier to give a bad 
prognosis than a good one. It is often the part of wisdom to 
avoid positiveness; haye something reserved. 



III.— THERAPEUTICS 

Strictly speaking, i; therapeutics" relates to all and every 
agency used in treating the sick, whether for cure or simple 
palliation; whether medicinal or instrumental. By common 
usage, however, the term is now-a-days restricted to the appli- 
cation of remedies; at least it is a very common practice. In 
a treatise on pathology, pure and simple, therapeutics would 
find no place; but in the present instance there is a necessity 
for some brief consideration of the topic. 

Of course the function of the physician is first and foremost 
to cure his patient, and this, too, in the speediest, safest, and 
pleasantest manner. Unhappily, there are cases, all too numer- 
ous, where a cure seems impossible, although the list of such 
incurable maladies is becoming shorter year by year. Even 
where a cure is possible, there are many occasions where there 
is an amount of pain and suffering that can only be slowly 
alleviated, or some product of the morbid action that may 
retard full recovery, and some additional measures must be 
resorted to, notwithstanding their successful application may 
only have a very secondary influence in reaching the desired 
results. For these reasons, as well as others that might 
readily be given, therapeutics must be approached from many 
sides, even if the term is used in the common restricted mean- 
ing. This fact leads to a more or less rational classification of 
the subject, something like the following: 

Palliative Therapeutics has reference to temporary relief, 
and may not lead directly to cure; in fact, as often practiced, 
it may retard or even forbid, cure. The use of opiates or 
anaesthetics would fall under this head, and is very commonly 

38 



THERAPEUTICS 39 

productive of great injury. Yet there are cases where the 
best prescriber stands powerless in the presence of acute suf- 
fering, and in his ignorance and helplessness is fully justified 
in resorting to such unscientific, valueless (for curative pur- 
poses), or possibly hurtful measures. Such a contingency, I 
believe, is found in recurrent carcinoma, and similar condi- 
tions confessedly incurable, and for which rational palliation 
has not yet been discovered. Palliation, in this sense, is to be 
sparingly and guardedly practiced, yet there are many times 
when no one would be justified in withholding the poor com- 
fort such a practice will afford. But there is another kind of 
palliation, one that is rational, and, in some sense, will have a 
curative influence, or at least materially aid other measures 
that are purely curative in design. Prominent among these, 
there will be noted position, in fractures, and other forms of 
trauma; heat or cold, in inflammatory affections, and many 
others. 

Adjuvant Therapeutics may be palliative, but the control- 
ling idea is something that will aid other and more legitimate 
kinds of treatment. Among the more common of these may 
be noticed poultices, in abscess; enemata, in constipation; posi- 
tion, in the approximation of wounds, and relaxation of mus- 
cular contraction, in fractures; diet, in gastric derangements; 
and improvements in sanitation, in epidemic or endemic out- 
breaks. Rational adjuvant treatment, based, of course, on sci- 
entific premises, is a matter of the utmost importance. All 
classes of practitioners, but particularly the surgeon — find it 
something indispensable. Routinism, as is always the case, 
often works positive injury; care must be had to employ such 
agencies on clear indications. 

Medicinal Treatment is, as a matter of course, the essential 
element in any case. It is true that there are few, if any, mor- 
bid conditions that are unaffected by the proper remedy. I 
am firmly of the opinion that all diseases are curable, and only 
by prescription on homoeopathic indications. Failure is due 
only to personal or general w^ant of "knowledge. The list of 
curable diseases is constantly being enlarged, and it is only a 



4° 



ELEMENTS OF SURGICAL PATHOLOGY 



matter of honest, systematic effort, on the part of the whole 
body of the profession when the "incurable" list will be com- 
pletely wiped out. It is irrational to suppose that any condi- 
tion of the body brought about by disturbed function, cannot 
be overcome by agents capable of restoring the lost equilib- 
rium. The morbid influences are quite as immaterial as the 
agents that are opposed to them. There are many influences, 
however, that operate to retard the full realization of our hopes; 
the most potent, apparently, is the constant attempt to discover 
a material mater ies morbi, the search for which has a sort of 
fascination for students in science. Works on practice, or 
theory, more properly discuss this question; it needs only pass- 
ing notice at this time. Yet while the indicated remedy is the 
essential element in the treatment of any case, the practitioner 
is withholding very much from his patient when he ignores 
proper palliation and adjuvants when needed. A point to be 
noticed is, that while the most satisfactory and typical form of 
administering the remedy is, as we say "internally," that is by 
the mouth— yet there are circumstances where this will be dif- 
ficult or even impossible. For instance, in dementia, coma or 
syncope, tetanus, atresia or stenosis of the pharynx, it might 
be impossible to give the remedy in the usual way. We may 
resort to subcutaneous injection, olfaction, or direct applica- 
tion. The two former are preferable to the latter, as the 
remedy is taken up* pretty much as though it were given by 
the mouth. The topical use of drugs is objectionable from 
every point of view. As a rule they are applied to raw-sur- 
faces, which are excreting. To enable the drug to be taken 
up the action must be reversed, that is, it must become absorb- 
ing, and thus the conditions become favorable for septic infec- 
tion. Another objection is, that the reparative elements, in 
wounds particularly, are injured, by dilution and otherwise, and 
repair is very materiallv retarded. This will be discussed 
later. Circumstances do arise, however, in which we seem to 
be compelled to resort to topical treatment, but I have never 
found the action of the remedy to be as good or prompt as 
when given in the orthodox manner. 



THERAPEUTICS 41 

Mechanical Treatment is both adjuvant and palliative, in a 
sense, but often is the essential element in many surgical affec- 
tions. This is particularly the ease in fractures, dislocations, 
deformities, such as talipes, and others. In such cases, how- 
ever, there is no question of morbid action; it is traumatism, 
malformation, or arrested development, and the conditions to 
be fulfilled are primarily of a purely mechanical character. In 
many of these cases remedies have a certain sphere and 
influence, but, which is somewhat unusual, their relationship is 
purely secondary. That is, no remedy can reduce a fracture, 
nor secure retention after reduction; neither is a remedy abso- 
lutely essential to consolidation, as the process is a physiolog- 
ical one, and in nine hundred and ninety-nine cases out of a 
thousand the consolidation surely comes without any treatment 
whatever. Occasionally, however, repair may be hastened by 
the action of the proper remedy, or if there is any defect it 
may be corrected. Mechanical therapeutics, therefore, is purely 
and solely of surgical interest. 

Instrumental Treatment includes all kinds of operations, 
as well as the use of diagnostic instruments of various kinds. 
The subject is too vast to discuss to a conclusion at this time, 
but something must be said of the sphere of operative surgery 
in connection with what may be called homoeopathic thera- 
peutics. 

There are at least two classes of practitioners in our ranks 
whose ideas of the scope of operative surgery cause much 
embarrassment; one give it too great prominence, and the 
other depreciates it. The former, whatever they may be as 
physicians, are very poor representatives of homoeopathy, as a 
rule. The latter, whatever may be their deficiences in broad 
medical scholarship, are good homoeopathists, using the term in 
its narrowest and most sectarian meaning. Neither of them 
advance the cause of either homoeopathy or surgery, but rather 
retard it. If the whole profession were compelled to attach 
themselves to one or the other party, great damage would 
result to both interests. Fortunately, however, there is a much 
larger party, at once conservative and progressive, notwith- 



4 2 



ELEMENTS OF SURGICAL PATHOLOGY 



standing the apparent contradiction, and it is to them, and 
through their efforts that we are to look for substantial gain to 
both surgery and homoeopathy. This peculiar state of things 
places the surgical specialist at a singular disadvantage. 
Cases come to him for an operation. The patient has been 
led to believe the necessity exists, and the physician has con- 
ceived similar ideas, indeed is responsible for the patient's 
belief. Now the surgeon, if he is a homoeopath as well, may, 
and often does see something better than an operation, but is 
not permitted to carry out his own ideas, as neither the patient 
nor physician will be satisfied with anything less than they have 
agreed upon. The surgeon will find himself accused of tim- 
idity, or ignorance if he dares decline the operation. This state 
of things stands as an obstacle to the development of homoe- 
opathy in connection with surgery. The ability to correctly 
determine whether an operation is imperative, or is to be pre- 
ferred to other means of treatment, is only to be secured by 
long study and experience. Those not in surgical practice 
have no right to assume judicial functions. Those who would 
deny any place for surgery in morbid processes, are often 
ignorant of the causes for disease, and are arguing on purely 
theoretical grounds, too often fanciful theories with no founda- 
tion in fact — and have no conception of what true surgery is. 
Those who have put it first in the therapeutic catalogue, are 
too often equally ignorant of the nature of morbid action, and 
more frequently with very hazy ideas of homoeopathic thera- 
pia. The true relation of surgery to morbid action cannot be 
dogmatically stated; at one time the circumstances of the case 
in hand will determine its position; in other cases there may 
be some generalization permitted. The whole matter is one 
of experience, not -personal, but of the profession as a whole. 
For instance, a patient has a tumor. Can medicine cure 
tumors? Unquestionably. Can medicine cure this particular 
case? Who can tell! The surgical specialist knows that 
many apparently innocent tumors become rapidly malignant. 
The only evidence we have of the incurability of a particular 
tumor is the fact that it becomes rapidly worse, and when the 



THERAPEUTICS 



43 



conviction is forced upon one that the remedies will not cure 
too often the surgeon sees that his art is also of no utility; the 
patient has passed the stage where surgery can offer anything. 
If a tumor was removed when in the innocent stage, there 
would be a reasonable hope for a cure. At least nothing has 
been lost but the tumor itself. The whole question may be 
roughly stated as follows: The patient that dies from an 
unnecessary operation, who might have lived without it, is no 
greater sacrifice to medical incompetency and ignorance than 
one who dies from the want of an operation that has been 
withheld. 

To sum up the whole question of therapeutics, it may be 
safely stated that there are very few cases, that are surgical in 
character, that call for any single species of therapeutics. In 
traumatism, arnica, aconite, rhus, or some other remedy, is 
often needed, in the absence of any existing indications, as a 
precautionary measure, or to anticipate conditions that experi- 
ence teaches may arise if it is not given. The practice of 
surgery cannot be looked upon as a mere mechanic art. The 
practitioner needs, for daily use, a good knowledge of thera- 
peutics, which alone will lead him astray. He must be a good 
diagnostician, with all therein implied, and even with all this 
at command, the state of knowledge to-day is such that he is 
frequently prevented from attaining anything like his ideal. 



IV.— SEMI-PATHOLOGICAL STATES 

There are certain conditions, in a sense physiological, that 
occupy the border line between physiology and pathology. 
Many words are used in medicine to-day, from long habit, 
that mean something very different from what they did origi- 
nally. Thus we find these semi-morbid conditions distin- 
guished by terms that are quite indefinite as used, and which 
may mean, and often are forced to do so, processes that are 
purely pathological. The conditions are such as represent a 
simple exaltation of function, something that involves no tissue- 
change, and leaves no structural defect behind it. At one 
time such a condition will be purely physiological, as occurs 
in the gastric hyperaemia accompanying digestion. Again, 
from unusual energy, duration, or frequent repetition, the 
same condition occurs, and is enduring, when it at once takes 
on pathological characters. Still again, it will occur remote 
from the actual lesion, only distantly, and yet actually, related 
to it, when it is once more physiological, but at the same time 
has a pathological relationship. Furthermore, as all patho- 
logical conditions commence in an exaltation of some function, 
these semi-morbid phenomena demand attention, particularly 
on the part of the surgeon. The translation of a reparative 
hyperaemia into a destructive inflammation is readily produced. 

IRRITATION. 

Undoubtedly there are two kinds of irritation. All func- 
tional acts are a response to suitable stimulus or irritant. An 
unsuitable irritant may and will arouse functional activity, but 
with an entirely different result. The forces of life, we have 

44 



[RRITATION 



45 



seen, have a double purpose, and are engaged in a double 
work. Firsts the maintenance of life and health, partly bv 
opposing disturbing influences. Second, the repair of injury 
done by disease or accident. Disease must always be es- 
teemed a confession of the defeat of the forces of life, either 
temporary or permanent, notwithstanding few, if any, escape 
being brought under morbid influences at some period of their 
existence. When the departure from health is temporary, 
and slight in degree, under fayorable circumstances nature is 
ultimately triumphant; but the victory may be materially 
hastened by the aid of art. Such cases, however, leave room 
for a reasonable doubt whether anything has been contributed 
bv the prescriber in bringing about the happy result. In the 
other case, when the condition may be considered permanent, 
in a sense, the lesion is such that the structural and functional 
integrity of the part is forever destroyed, as far as nature's 
efforts to cure alone are concerned, and if victory is secured 
at all it is at a fearful expense and with permanent loss. To 
repeat, disease is not to be considered an essential element of 
life; and in spite of apparent recovery, every attack that is 
associated with structural lesion leaves an indelible impress of 
its operation, and to a certain extent shortens the life of the 
sufferer in proportion to the disturbance of function. 

The prophylatic function is operative just so long as perfect 
equilibrium in the forces of life is maintained; as a virtue car- 
ried to excess may become a fault, just so may a physiolog- 
ical function, being exaggerated, pass into a pathological state. 
Thus a transitory irritation of the eye may result in a simple 
and short-lived conjunctivitis; prolong the irritation, or repeat 
it frequently, and the transient hyperemia becomes inflamma- 
tion, with possibility of grave injury to the organ. In the one 
case we have a simple protest against the irritant; in the sec- 
ond a yielding to its influence, and a consequent loss of struct- 
ure to repair. It has been said that "a. perfectly healthy 
individual never knows that he has any organs," their functions 
being carried on in such a silent and orderly manner that no 
feeling of discomfort is ever produced. To know that one has 



46 ELEMENTS OF SURGICAL PATHOLOGY 

an organ, in this sense, is to know that "something ails it." 
A perfectly normal stomach, one that never suffers abuse, may 
on an occasion have an unusual amount of work forced upon 
it by some indiscretion or excess in eating, the task is per- 
formed, at some expenditure of force, and if not too frequently 
repeated, only a temporary inconvenience is experienced. The 
organ of sight may be overtasked until it becomes so sensitive 
that every effort is made to protect it from that light which 
before was grateful to it. In either event there* is increased 
amount of blood in the part, and some of the ordinary symp- 
toms of inflammation, but no structural change has taken place, 
no lesion is discernable, and the duration of life is not visibly 
shortened or imperilled, either in the part or the organism as a 
whole. The Latin word irrilare, from which our word irrita- 
tion is derived, signifies to "fret,"' to "pull," to "excite," and 
admirably expresses what may be defined as a temporary exal- 
tation of function. 

There is another condition in which from long continued 
debilitating influences, local or general, anaemia results. The 
same conditions of irritation of the starved parts now exists as 
when the state is hyperaamic. In either case there is a protest 
against insufficient nutrition, either as to quantity or quality. 
In the one case there is deficiency in the amoitnt, and corres- 
ponding deterioration of the elements; in the other there is no 
lack of quantity, but the innutrition exists from a -post perfec- 
tion of the blood so often characteristic of hyperaemia. What- 
ever the condition may be, however, as to supply of blood, 
plus or minus, the peculiar characteristic of irritation is func- 
tional exaggeration without structural change. 

The sensations of the patient, the subjectivity, does not rep- 
resent pain, but unusual sensibility; a simple illustration is thus 
given by Billroth {Snrg. Path, sj) • "You now see my 
occular conjunctiva of a pure bluish white, like that of any 
normal eye. Now I rub my eye till it weeps, and the conjunc- 
tiva becomes reddish; perhaps with the naked eye you may 
see some of the larger vessels — with a lens you will also see 
the finer vessels full of blood. After five minutes, at most, the 



IRRITATION 



47 



redness has entirely disappeared." Here has been no pain, 
no change in tissue, no change in function; a slight, very slight 
elevation in temperature, a momentary excess of blood in the 
part and the whole process passes away. When there is pos- 
itive pain, and the function is slightly perverted, the condition 
ceases to be one of simple irritation and becomes some kind of 
pathological state. 

It is the fashion to speak of irritable bladder, irritation of 
the spine, or irritation of the brain or heart, when an actual 
pathological condition is understood. It is true the anatomical 
characters are not always understood, but there is more than a 
simple exaltation of function; there is a permanent abnormal- 
ity, perhaps due to causes operating at a distance. Thus it has 
long since been shown that irritation of a sympathetic gan- 
glion will produce exalted action in the organs or tissues under 
its influence; a section of the nerve will produce cessation of 
action. Now in irritable heart, if we look for the cause in the 
heart, itself, we may find nothing, and thus conclude that it is 
true irritation. If we remember the teachings of experimental 
physiology, we will extend our investigations to the inferior 
cervical ganglia, and the roots of the par vagus, and often will 
find some lesion there that at once places the cardiac irritabil- 
ity in a pathological group. When the exalted functional 
action is intermittent, at least not constant, and no local or gen- 
eral lesion is discoverable, that might operate as a cause, the 
term is proper and eminently suggestive. The moment some 
structural change occurs, however, no matter how slight, so 
that some effort at repair is demanded, at that moment the 
condition becomes something more than a simple irritation; it 
is then pathological. 

Looked upon from a purely pathological stand-point, the 
irritation that converts a physiological into a pathological activ- 
ity, is of one of three characters. It may be normal in kind, 
but too frequently repeated; it may be of undue intensity; or 
it may be something specific, as arsenic, or some other chem- 
ical substance. 

Therapeutics. — Conceiving irritation to be the commence- 



4 8 ELEMENTS OF SURGICAL PATHOLOGY 

merit of organic change, and knowing, experimentally, the 
sphere of action of aconite, viz., commencing in vaso-motor 
irritation, with suppression of excretion, followed by reaction- 
ary exaggeration — we rind this remedy of the first importance. 
It requires early administration, however, in the beginning of 
the acute stage. Also, it should be noted, when irritation is 
due to morbid action at a distance, the treatment must ignore 
the secondary irritation entirely. 

SYMPATHY. 

Sympathy, otherwise i; reflex pain." is a condition closely 
allied to irritation. It refers to phenomena, not necessarily 
pain — felt at a point remote from the actual lesion. It is 
something of very common occurrence, and has excited much 
discussion; there is, even now. apparently, quite as much 
obscurity, as to the actual cause, as there was fifty years ago. 
Some writers have thought the phenomena were due to a con- 
tinuity of structure; others that it was a question of contigu- 
ity; some refer it all to nerve supply; and still others esteem 
it to be dependent upon a similarity of structure or function, 
one or both. We are justified, I think, in concluding from a 
study of such evidence as is at hand, that in many cases, if not 
all — the four conditions are associated, or at least more than 
one will have a causal relation to any case. 

Continuity of Structure is apparently explanatory of the 
itching of the meatus which is such a constant accompaniment 
of vesical calculi. There are many cases of stone in the blad- 
der in which this symptom is not only. the earliest and most 
persistent, but is practicallv the only one. Adenitis accom- 
panying lymphangitis is another instance. 

Contiguity is explanatory, apparently, of the spasms of the 
diaphragm so common in gall-stone colic. 

Similarity in Structure it is said, accounts for metastasis of 
mumps, to the testicle particularly, and yet is not sufficient. It 
has been argued that certain organs of similar structure, when 
acted upon by some morbific agency, take on active morbid 
conditions by virtue of some accidental occurrence. That 



SYMPATHY 



49 



other similar organs are brought to the verge of such a catas- 
trophe, but the outbreak occurring in another, exhausts itself 
there. Now, with this predisposition, any slight exciting 
cause may well excite active morbid action in other similar 
struetures. But this does not solve the problem of metastasis. 
It is one of the facts in pathology, and there are many such — 
where we must be content with the fact itself, the causes being 
undiscoverable. 

Similar Nerve Supply must be a potent factor in a great 
many of those mysterious •• sympathies " we meet. The occur- 
rence of odontalgia, or the reverse — as a complication of facial 
neuralgia, is sufficientlv common. It will also alone serve to 
account for the spasm of the diaphragm in hepatic colic, and 
the irritation of the meatus in vesical calculus. 

Perhaps one of the commonest instances of sympathy is the 
pain in the knee accompanying the earlier stages of hip-joint 
disease. Here we have continuity in structure in the fascia- 
lata: similarity in structure is notable: similar nerve supplv 
through the sciatic is apparent. Apparently all of these fac- 
tors enter into the explanation, neither taking rank over the 
other. 

It would be profitless, in the present state of knowledge, to 
discuss this question at greater length. We recognize the 
fact, and all else is mere speculation. 

With reference to nervous influences, a word or two addi- 
tional is needed. A nerve is practically a simple conductor; 
it originates nothing. The energy it transmits is originated at 
the center with which it has anatomical relation. An irritant 
applied or operative at the root of a nerve produces phe- 
nomena at its distribution. Gradually, if the irritation is con- 
tinuous, the whole length of the nerve will become involved, 
because it is not an inorganic conductor. On the other hand, 
an irritant applied at the termination of a nerve will give rise 
to phenomena at that point, and later affect its whole distribu- 
tion, and possibly related tracts will become involved. Simi- 
larly, irritants applied in the course of the nerve will gradually 
affect the trunk in both directions. These facts are mentioned 



5o ELEMENTS OP SURGICAL PATHOLOGY 

to call attention to the necessity for careful study in all so-called 
"reflexes," remembering that the lesion may be at the root as 
well as the termination, or even somewhere in the course of 
the nerve. 

As to therapeutics, little is to be said. The symptoms are 
delusive, and afford little assistance in the selection of a rem- 
edy. They may be of value for purposes of diagnosis, and 
thus indirectly lead to proper treatment. In one sense, how- 
ever, and in a certain class of cases, important therapeutic 
indications are furnished. When metastasis occurs, I think it 
good practice to secure a retranslation, if possible; for this 
purpose arsenicum has given me very excellent results. Even 
where retranslation is not secured, this remedy is often promptly 
curative. 



V.— AN/EMIA 

Strictly speaking, the word -anaemia" means a want of 
blood, and has reference particularly to a deficiency in quan- 
tity. Practically, or as the word is used in the profession, it 
means any inadequacy, either loss of property, or deficiency 
in quality, as well as a loss in quantity. The question has 
solely to do with the ability to carry on its function. The 
function of blood is quite complex; possibly it may be coyered 
under three heads. An important function is as an excitant to 
function in the yarious organs, a sort of stimulating property. 
This is largely due to the oxygen carried, and consequently is 
more marked in the arterial system than the yenous. Any- 
thing which would preyent proper aeration of the blood must 
rob it of the property conferred by the oxygen. 

Another function is to repair waste, also an attribute of the 
arterial blood through the haematoblasts, leucocytes, and other 
organic constituents. Defects in assimilation of food, undue 
molecular waste, or some mechanical interruption of the cur- 
rent, must result in loss of nutritiye properties, either relatiye 
or actual. 

A third property is that of excretion, or elimination, the 
remoyal of worn-out material. This is very largely a venous 
function. It is a highly important one, however, as it is easy of 
demonstration that defecation is as important as nutrition, pos- 
sibly more so. 

We will see that the causes for any one or all of these 
changes in the blood are many, and that the loss of any one 
function must operate primarily as though a certain quantity 
of blood were withdrawn from the body. Pressure of tumors, 

E 2 5I 



52 



ELEMENTS OP SURGICAL PATHOLOGY 



lesions of the respiratory apparatus, increased waste, imper- 
fect food assimilation, or some error in the production or 
renewal of the blood, are all among the causes that may pro- 
duce anaemia. In other words, the full and perfect functional 
attributes of the blood are dependent upon, first, adequate 
manufacture; and, second, normal circulation. The particular 
consequence of any such loss must depend upon many consid- 
erations, as whether the disturbance is general or local. The 
question of quantity is necessarily important, but the prime 
question here is as to the probabilities of renewal, that is, 
whether it is an abstraction due to accident, with the blood- 
making functions unimpaired, or a loss from deficiency in pro- 
duction. For convenience, therefore, we must study the phe- 
nomena attending general poverty of the blood, or ancemla 
proper; a local loss, or Ischcemla; or an accidental abstraction, 
surgical anaemia. 

Anaemia, without any qualification, refers to a general im- 
poverishment of the blood, whether from loss in quality or 
quantity. We find that this condition may be pathological, 
physiological, or traumatic, otherwise surgical. 

Physiological Anaemia is shown in the diminished blood 
supply during functional rest, and sleep, Any functional act, 
voluntary or automatic, determines an increased blood-supply; 
the cessation of the act shows a diminished quantity of blood 
in the part, or, as in sleep, a slowing in the circulation. Thus 
the tension in the vessels in different parts of the body is not 
at all times the same. It is quite uniform and stable in the 
large trunks, as the aorta and first subdivisions, but varies 
greatly in more remote vessels. Such temporary loss of 
blood is not only consistent with health, but is one of the evi- 
dences of proper physiological perfection. 

Pathological Anaemia, on the other hand, is something 
standing for a defect in manufacture. The losses or modifica- 
tions are of many varieties. There may be an excess of 
serum, relative or actual; or some change in the size of the 
red corpuscles, as microcythagmia, when they are too small; 
or macrocythaemia, when they are too large; there may be an 



A N.K.MIA 53 

excess of white cells, as occurs in leucocythsemia; or there 
may be a tendency to coagulation, as in some fibrinous states 
of the blood, or the opposite, as in pyaemia, or some forms 
of toxaemia — where coagulation cannot be produced, the blood 
remaining fluid. There may also be a simple diminution in 
quantity, all the elements being present in due proportion, but 
the bulk inadequate. There is, of course, much variation in 
the symptoms produced by these varying states, and yet there 
are common characters. The changes in the blood are only 
to be detected by microscopical examination, which examina- 
tion will often lead to a correct diagnosis as to the cause, and 
the particular function at fault. 

The commoner general symptoms are as follows: decolora- 
tion of mucous outlets of the body, as well as the integument; 
lowered temperature, as a rule, with occasional flushing, and 
flashing of heat. The extremities are notably of low r tempera- 
ture; possibly the thermometer will show only slight falling, 
but the subjectivity is marked. Often, with the coldness, 
there is unnatural moisture. Sometimes it is only a feeling of 
moisture, on the part of the patient, none being observable on 
examination. The pulse is weak, rapid, or slow; murmurs 
are heard in the sub-clavian regions. Frequently there is 
cedema, particularly of the lower extremities, and under the 
eyes. The mouth is dry, not always with thirst; in fact, the 
mucous surfaces generally are dry. The urine is often scanty, 
the specific gravity sometimes high, and again low. The 
bowels are irregular, with a tendency to constipation, although 
in other cases the stools are more or less diarrhceic. Menstru- 
ation is irregular, scanty, pale co^r, and short duration. All 
the functions are more or less disordered; appetite poor and 
capricious; sleep light and unrefreshing. There is nearly 
always considerable emaciation, although occasionally it is not 
marked, and sometimes is disguised by a puffiness that does 
not amount to cedema. 

While all classes of people, all ages, and of both sexes, are 
liable to anaemia, yet it is more frequently met with among 
women, particularly at the age of puberty, and the climac- 



54 ELEMENTS OF SCRGICAL PATHOLOGY 

teric. After the establishment of menstruation it is more 
common among those who have borne children, particularly 
if the pregnancies have rapidly succeeded each other. It is of 
frequent occurrence in malarial districts, or in communities 
where endemic conditions induce the inhabitants to use much 
medicine habitually, notably quinine. 

Therapeutics. — In a very large number of cases, the treat- 
ment will be hygienic, dietetic, or gymnastic. Habits of life 
must be changed; out-of-doors exercise enforced; clothing 
suitably selected, and in short, a general correction of faulty 
habits. Such items cannot be enumerated; they are to be 
governed by the circumstances in each case as they arise. 
There are many cases, however, in which the physician, from 
habits of routinism more than anything else, assumes all cases 
of anaemia to be of a character due to some faulty habits, 
and fails to look for some governing lesion. Possibly one-half 
of the cases occurring among young people are easily cured 
by such measures as have been alluded to. Among older 
subjects this is not true: the large majority are of true patho- 
logical character. 

Remedies, in all cases, will greatly aid the hygienic and 
other measures, may even possibly cure without their aid at all. 
In the purely pathological cases they are sine qua uon; no 
amount of merely hygienic measures will cure without their aid. 
By remedies is meant drugs given on homoeopathic indica- 
tions, not as foods, or stimulants, on any physiological suppo- 
sition. If the urine is found loaded with salts of lime, it is far 
from being an indication to give it as food in massive doses. 
The fact that it is excreted is good evidence that there is 
enough of it, and that there is a fault in assimilation. The 
organism fails to take up that already supplied, and cannot 
take care of any additional amount. There are few remedies 
in the Materia Medica without some relation to anaemia; it 
will be impossible to mention even those most frequently indi- 
cated at any length. Perhaps, to put it roughly, the so-called 
' ; anti-psorics " are oftener called for. There are five that have 
probably been oftener used in my practice than any others. 



A X.K.MIA 



55 



Calcarea C \rrlh This remedy must take first rank. The 
special indications are familiar enough. There is the puffy 
face, particularly the upper lip; the pasty complexion; coldness 
and dampness of the feet and hands; protuberant abdomen; 
shortness of breath; hacking cough; perspiration about the 
head and neck at night; "taking cold" easily, chilly; and 
tendency to catarrhal inflammations generally characteristic of 
the remedy. 

Arsenicum Alb. The indications are very different from 
those of Calcarea. The skin is dry, feeling parchment-like; 
palms of hands and soles of the feet hot; thin, scrawny habit; 
diarrhoea is a common occurrence, and is watery, hot, and very 
exhausting. Patient is apt to feel chilly, notwithstanding the 
hot hands and feet, and is very weak. 

Apis mel. The indications are somewhat similar to those 
of Calcarea. Puffiness of the face, particularly under the eyes; 
scanty urination; skin easily irritated and excoriated; oedemas, 
in different parts of the body, particularly the upper parts; 
biting-stinging in the swollen parts. 

China off. The symptoms are typical of anaemia; ringing 
in the ears; faintness on rising up suddenly; diarrhoeic ten- 
denency; great weakness; dimness of vision. 

Ferritin met. Also the common symptoms of anaemia; 
particularly face flushes on every exertion; watery, painless 
stools, with little, if any exhaustion following. Bowels often 
constipated for days, and then a hard stool, followed by watery 
diarrhoea, containing undigested particles. 

Sulphur. Something similar to arsenic. Skin dry, rough, 
and irritated easily; formication or itching when heated; 
water, hot or cold, aggravates the skin symptoms. Soles of 
the feet so hot, that the feet are kept uncovered at night. 
Diarrhoea, particularly early in the morning, with sudden urg- 
ing. 

Surgical Anaemia, is a loss of blood from accident, or sur- 
gical operation, and differs from pathological anaemia in all 
particulars. In the first place there is not necessarily any defi- 
ciency in the blood-making function. The reproduction is 



56 ELEMENTS OF SURGICAL PATHOLOGY 

usually speedily secured, unless the amount lost has been very 
excessive. The immediate consequences are of the first 
importance, dependent upon the amount of blood lost and the 
conditions attending it. When from accident, the blood-mak- 
ing function is presumably normal, and reproduction at once 
commences. When lost from surgical operation, there may 
have been some defect in this particular, and the repair will be 
slower. The symptoms are those of haemorrhage and ma}* be 
tabulated as follows : Faintness, rapidly increasing, with low- 
ering of temperature, dimness of vision, ringing in the ears, 
and loss of color. There is usually great thirst. In extreme 
cases there is syncope, during which the haemorrhage usuallv 
ceases, but it recommences with returning consciousness; then 
syncope again. In fatal cases there are usually convulsions 
before death. When the haemorrhage is arrested, there will 
be profound debility, lowered temperature, mind more or 
less disturbed, particularly apathetic; thirst and ringing in the 
ears are quite persistent. On raising the head, syncope often 
occurs. 

Treatment depends upon the amount of haemorrhage and 
urgency of the symptoms. The objects are first to meet the 
immediate demand for blood, and next to hasten its reproduc- 
tion. 

When a large amount of blood is suddenly taken from the 
body, the consequences are first felt at the nerve centers, par- 
ticularly the brain. In consequence of this the heart, in com- 
mon with all organs essential to life, loses at once the stimulus 
furnished by the nerves governing it, and the loss of blood 
entering it. From the combined operation of these two con- 
ditions, syncope is produced. The recumbent posture has the 
effect to at once furnish more blood to the brain and to lessen 
the work of the heart. In all serious haemorrhages, therefore, 
the recumbent posture must be secured, with the head low. 
If the symptoms still seem serious, or unabated, there are 
various forms of transfusion to be practiced, which will be 
briefly referred to, as the whole subject belongs more properly 



AN.EMIA 57 

Transfusion is the injection into the blood vessels ef blood, 
human or animal, or its equivalent. It also refers to furnish- 
ing blood to the life centers from distant parts of the body. 
We find the process may be mediate, immediate, or auto-trans- 
fusion. 

Mediate Transfusion is effected by collecting the blood 
from a donor, in some suitable vehicle, with facilities for main- 
taining a proper temperature, freeing it of fibrine, by " whip- 
ping," and then injecting it into the veins of the recipient. The 
dangers consist in the presence of fibrine, whereby coagulation 
mav occur, and embolism ensue. Also of some objectionable 
character of the blood, from chronic morbid action particularly. 
At one time this method was quite extensively used, but the 
results have not been particularly favorable. Blood from the 
lower animals is not to be used. 

Immediate Transfusion is the transfer of blood directly from 
the veins of the donor to those of the recipient, by means of a 
suitable apparatus. The principal precaution is to avoid the 
admission of air together with the blood. This method has 
given much better results than the former, but the final out- 
come has not been such as to give it an unquestioned place in 
therapeutics. It must be admitted, how r ever, that the cases in 
which it has been employed were of the most desperate char- 
acter, and while immediate improvement has been the rule, the 
later results are not good at all times. 

Auto-transfusion is a purely temporary measure, but one 
of great value. It is secured by bandaging the extremities, 
lower or upper, or both, with elastic bandages, driving their 
blood to the centres. If reproduction of blood is active, it 
mav prove a curative measure, care being taken to remove 
the bandages one at a time, with an interval of some minutes 
between — to avoid a too sudden abstraction of blood from the 
centres, or in too great quantities. The last bandage may, 
on occasions, be continued for two, or even three hours; 
probably the first one should be removed after an hour, or a 
half hour longer. Less energetic methods of auto-transfusion 
have long been known and generally practiced, if not for 



58 ELEMENTS OF SURGICAL PATHOLOGY 

surgical anaemia, at least as prophylactic. The most common 
is secured by elevating a member, and stroking it, towards 
the body, with the two hands, thus emptying the veins, the 
position operating to retard their refilling. 

There are many compromises with transfusion, the most 
common being milk, and the so-called " normal saline solu- 
tion/' Milk has almost entirely ceased to be used, for many 
reasons. The saline solution is growing in favor, and many 
brilliant results have been secured. It is particularly useful 
in true surgical anaemia, that is after severe haemorrhage, 
where there is fair promise of ample reproduction of blood.. 
Whether it acts as a pure stimulant, or by furnishing resist- 
ance to the heart and vessels by giving them something to 
act on, or by a direct influence on the blood-making function, 
or by its influence directly on protoplasm, or by an association 
of all of them, cannot be definitely said. It is prepared accord- 
ing to the following formula: 

Distilled water, 2 pints; common salt, \ Y / 2 drachms; liquor 
sodae, 20 drops. The ;i normal serum" of the biologist is 
one-sixth of one per cent, of salt; the soda, however, seems 
to be an important ingredient. One or two pints, or even: 
more, of course of proper temperature — have been injected 
into some large superficial vein, in cases of impending death,, 
with instantaneous improvement in pulse and temperature,, 
and good recovery. In homoeopathic practice, no matter what 
form of transfusion is employed, China must always be given, 
from its known influence on the blood-making function. 

Ischsemia. — This form of anaemia is purely local, limited 
territories being deprived of blood in various ways. Thus 
the pressure of tumors; the obliteration of vessels from 
any cause; the pressure from dislocated joints, or displaced 
fragments in fractures, are among some of the common 
causes. The consequences depend upon the extent of the 
process, and the cause. When from pressure, or such condi- 
tions as ligaturing vessels, or almost any form of purely 
mechanical obstruction, the circulation is reestablished (col- 
lateral circulation), and no permanent damage is done. When 



A X.K.MIA 59 

it is caused by morbid action, such as embolism, or inflam- 
mation in small vessels, ulceration is probable; when the 
same conditions occur in larger vessels gangrene will follow. 
Again if vessels essential to life are affected, or the parts sup- 
plied bv the vessel are of the first importance, death will ensue. 
Thus embolism of some of the cerebral vessels, will produce 
ischaemia of the brain, and imperil life; so with the pulmonary, 
hepatic, or coronary arteries. 

Treatment is simple in theory, but often extremely difficult 
in practice. The first indication is to remove the cause, of 
course, if that can be reached. By external warmth, position, 
and possibly friction, collateral circulation may be hastened. 
Also, when embolism is recognized, Arnica is used to hasten 
absorption, massage, if accessible, may break it up, the frag- 
ments going to smaller and possibly less important vessels. 

Scale and Bell., have been useful in such cases, when the 
svmptoms call for them, as indeed will any other remedy 
under the same circumstance. In the absence of symptoms, 
however, on purely general indications, Arnica is the remedy 
that would be first suggested to the homoeopath. 



VI— HYPEREMIA 

As was found to be the case in anaemia, the conditions of 
hyperaemia may be physiological or pathological. The term 
refers to an over supply of blood, local or general, relative or 
actual. The term '-plethora" means a general increase in 
the amount of blood in the body, or such a change in its com- 
position that it might be considered " post perfect," as Poland 
has it. The term ''hyperaemia" refers to . a local excess, 
standing as the opposite to isckcemia. Plethora being a con- 
dition almost wholly medical in character, or in the domain of 
general pathology, concerns us but little at this time; an 
account of the phenomena attending hyperaemia will be suffi- 
cient for the purpose in hand. 

All functional acts are accompanied by increased amount of 
blood in the parts concerned, already alluded to in an earlier 
paragraph. This is occasional, and passes away, under nor- 
mal conditions, leaving no lesion behind it. It is essential to 
functional activity, and has no pathological significance what- 
ever, unless too frequently repeated, or the irritant is of undue 
intensity, or prolonged application. In one case it will be a 
protest against an irritant, constituting the semi-pathological 
state already referred to, known as irritation. In another case 
it will be an element in repair, after injuries of any kind, and 
while of higher grade, and more persistent, is still physiolog- 
ical because the outcome is conservative, and not destructive. 
Should the condition outlive the emergency, however, and be 
accompanied by some degeneration in structure of the part 
involved, pathological characters are then assumed. 

Viewed as a purely accidental and temporary occurrence, 

60 



HYPEREMIA 61 

or as associated with purely mental emotions, as in the act of 

blushing — the process is exceedingly simple. But when it 
results from injury, or from morbid influences, one of two 
things is evident: either the state will pass over into inflam- 
mation, or it will remain as a reparative process. In either 
case the blood will undergo a notable change, and assume 
some character not present under other circumstances. In 
the physiological forms, purely, attendant upon function, the 
blood is not in any sense changed; the sole phenomena is 
increased amount. In repair of injury, there is a change in 
composition, but only by the addition of the elements for 
repair in unusual amount. It is still physiological, to all intents 
and purposes. In commencing inflammation, it has undergone 
changes that render it unfit for nutritive purposes, and hence 
the condititon is pathological. Furthermore the tissues are 
imperilled thereby in various wa}/s. 

Experiments have shown that the effects of irrritation of 
nerves, governing the circulation of the blood, so far as it is 
influenced by contraction of the vessels, varies with the point 
of irritation, i. e. whether peripheral or central. The blood 
circulates in the vessels through the combined agencies of the 
heart's contraction, the dilatation and contraction of the vessels 
themselves (resiliency), the automatic action of muscles lying 
in close relation, and to some extent, the action of gravity. 
The dilatation of the vessels is due almost entirely to inter-vas- 
cular pressure from the blood forced in by the heart's action, 
the muscular fibres having no power to dilate the vessel other 
than by ceasing to contract, and thus yielding to the pressure 
from within. The contraction of these fibres, however, is 
under the control of the vaso-motor system, which, I am of 
the opinion, has a partially inhibitory influence, the direct 
stimulus to contraction being probably the same as in the case 
of the heart itself. I am aware that Stricker, of Vienna, 
holds a different doctrine, which will be found fully elaborated 
in the International Cyclofcedia of Surgery, Vol. i. He there 
attempts to show that there are two sets of vaso-motors, one 
dilating and the other constricting. His arguments are 



62 ELEMENTS OF SURGICAL PATHOLOGY 

ingenious, but almost entirely unsupported by demonstrable 
facts, being furthermore opposed, it seems to me, to the usual 
if not uniform principles of vital mechanics, if the term may 
be allowed. It is not shown that a vessel, or any other 
tubular organ, has been observed to expand or dilate indepen- 
dently of the introduction of interior tension or pressure. Now 
a direct irritation of a part, as a prick with a needle, or the 
application of a concentrated acid, will show a momentary 
contraction of the vessels, at times so short in duration that it 
may entirely escape detection. If the irritation is central, 
however, say at the ganglia or root of the nerve that supplies 
the system of vessels under observation, the immediate effect 
is dilatation. This difference is not without significance. 

The contraction of the vessels, in the first instance, is due to 
a sudden, almost tetanic muscular effort, the subsidence of 
which leaves the fibres exhausted or momentarily paralyzed. 
In the second case, when the irritation is central, the vessels 
are dilated from a suspension of nervous energy at its source, 
the muscular fibres becoming relaxed from this cause. These 
different states will require separate study. 

A constriction, even momentary, in the course of the cur- 
rent of the circulation, will not have the effect that narrowing 
the channel of a river would have, which is to increase the 
rapidity of the current; it retards, during its duration, the whole 
current of the blood. This retardation is'followed by a corres- 
ponding quickening of the current upon the release from con- 
striction, only to a certain extent, during which time a greater 
quantity of blood passes through the part than is usual, for a 
moment raising the temperature slightly, and giving an increase 
of color in superficial parts. Now the plasticity of the blood 
depends upon the relative amount of albuminous elements 
present, and the reparative ability of the blood is directly in 
relation to the same consideration; an amount of blood com- 
pressed into a space ordinarily occupied by a much smaller 
quantity, will contain, as related to the tissues of the part, 
much more plastic material. This induces a relative change 
in the character of the blood peculiarly fitting it for reparative 



HYPEREMIA 63 

purposes. More than this: the dilatation being of longer 
continuance than the period of contraction, the impulse to the 
circulation is lost, at this point, from the inaction of the mus- 
cular fibres, and the larger amount of blood is slower in pass- 
ing through the dilated vessels than . before the contraction 
occurred. 

This has still another significance. The vessels affected by 
this dilatation while furnishing ample accommodation for the 
influx of the increased amount of blood, does not furnish 
increased facilities for letting it out. This operates as an addi- 
tional barrier to the restoration of the equilibrium, and makes 
the period of dilatation far exceed in duration that of contrac- 
tion. Furthermore, all of these various interruptions greatly 
add to the plasticity of the blood, increasing as Simon says, 
its •• fibriniferous character." 

What has been said may now be summarized as follows: 
Local, or peripheral irritation, causes primary constriction, 
and secondary dilatation of the vessels involved. The dilata- 
tion practically increases the plasticity of the blood. The 
increased plasticity so alters the characters of the blood that 
reparative material is at once at hand to repair the damage 
done by the irritant. The continued action of the irritant, as 
in wounds, or the frequent repetition, as in habitual pressure 
or friction, causes such a lesion that the demand for repair 
induces what the old pathologists called "adhesive inflamma- 
tion," but what is now known to be a purely physiological 
process, although somewhat exaggerated, as given above. 

Supposing the irritation has been so severe, or of such a 
character, that the capillaries are torn and extravasation of 
blood occurs into the surrounding tissues, we have the same 
state of affairs intensified. The coagulation of the effused 
blood forms a material barrier to the continuance of the circu- 
lation. The conditions are now favorable to inflammation, but 
whether it shall be set up, or active repair, will depend upon 
other contingencies to be studied later. It may be noticed at 
this time, however, that there is a condition in hyperaemia, 
particularly when attendant upon processes of repair, that 



6 4 



ELEMENTS OF SURGICAL PATHOLOGY 



might lead careless students to suppose there was some iden- 
tity in the processes; this is the appearance of white blood- 
corpuscle's in the tissues of the part. We will learn later that 
in the case of inflammation, these lymphoid bodies make their 
escape through the walls of the vessels by vital processes, 
apparently inherent. In the case of traumatic hyperemia the 
escape is made as elements of the blood, through the wounded 
vessel. One represents an accident, the other a design, and 
are consequently not identical either in method, purpose or 
significance. 

This is a fair resume of the state of knowledge of hyperse- 
mia where there is no pathological alteration in the blood, and 
w T here the irritation is peripheral. Let us now enquire what 
the differences are when the irritation is central, as in blushing. 

Central irritation as has been already remarked, produces 
primary dilatation of the vessels under the influencs of the 
nerve or ganglia irritated. The condition is similar to men- 
tal emotions, with this difference, however, that the primary 
disturbance is in the heart, whilst, when other causes prevail 
the heart partakes secondarily. For instance, under central 
irritation muscular action in the middle coat of the vessel is 
suspended; it is not a localized condition, but extends through- 
out the whole system of vessels under observation. For the 
reason that it is general, the volume of blood in the part is 
greatly increased, the suspension of contractility resulting in a 
relatively slower egress than ingress. When this is evanes- 
cent a strong contraction at once comes on, emptying the ves- 
sels as fast as they were filled. The sudden rush of blood in 
these enlarged vessels to some considerable extent empties 
the sources of supply interior to them, automatically causing 
a deep or hurried inspiration, having the effect to cause an 
equally forcible cardiac contraction, which instantly fills the 
partially depleted vessels, perhaps increasing the tension. The 
tension being increased there is a stronger reactionary con- 
traction than usual, the effect on the vessels being slightly 
anaemic; and this oscillation goes on until equilibrium is 
restored. Now in all these conditions there is no change in 



ilYl'KK.KMIA 65 

the character of the blood, for the double reason that there is 
no retardation in the velocity of the current, and no lesion to 
repair. The process is purely one of irritability, a temporary 
exaltation of function. 

Suppose the heart is primarily affected by mental emotions, 
the first effect, in some instances, is an interruption of rhythm, 
followed by a powerful and spasmodic contraction, forcing an 
unusual amount of blood into the vessels, producing extraor- 
dinary increase of tension. There is no special irritation of 
the muscular fibres now, they do not necessarily partake in 
the cardiac irritation, the vessels being dilated simply from 
the suddenly increased quantity of blood thrown into them. 
This sudden distension is followed by reactionary contraction, 
and pallor succeds the primary flushing of the surface. The 
kind of emotion, for reasons not understood, exercises a pecu- 
liar influence as fear, joy, etc., the expression of which is 
well known, and the explanation readily found in the fore- 
going paragraphs. 

There are circumstances where in lieu of irritation of a 
nerve there is actual paralysis, as when a trunk is divided or 
strongly compressed. The vessels now dilate as when from 
irritation, but it is -permanent ; the blood circulating in the part 
only by the impulse derived from the heart, the action of 
gravitation and the slight pressure of surrounding muscles; the 
contractility of the vessels is lost. If the current happens to 
be ascending, as in the cranial region, gravitation is not only 
lost as a factor in the circulation, but is turned into an oppos- 
ing element. Under these circumstances stasis of the blood 
is imminent, a point has been reached where hvperaemia 
almost inevitably passes over into inflammation, and our 
studies in this direction have reached their limit. 

We are now prepared to understand that the prodroma of 
morbid states are not necessarily morbid in themselves; they 
are simple functional excitements which may cross the line 
and become organic lesions, or subside, leaving no trace 
behind them. Thus the irritant, tangible or intangible, material 
or emotional, "frets," or excites the part under its influence; 



<56 ELEMENTS OF SURGICAL PATHOLOGY 

the continuity, contiguity and nervous relation with other 
parts, near or remote, induces a sympathy in the perturbed 
function; the combined effect of irritation and sympathy, 
induces more or less hyperasmia, or vascular excitement, and 
other conditions now determine the results. 

What has been written, however, on these semi-patholog- 
ical conditions, must be taken as a simple preface to an immense 
field for study. The topic is of as much interest to the physi- 
cian as to the surgeon, and must enter more or less, into all 
his conceptions of etiology. It is impossible for the student 
of surgery to shun this enquiry, as it includes the elements 
of the science of his calling. 

Therapeutics. — The treatment of hyperemia, when it 
assumes pathological characters, is very simple in the acute 
form; Aconite is the typical remedy, and will rarely fail in 
bringing about full reduction. In chronic cases, the list of 
remedies is a long one, but as the condition is then practically 
an inflammation, the special indications will be found under 
that head. Palliative measures are quite valuable adjuncts, 
rest taking first rank. As to heat and cold in this connection, 
possibly there is room for much difference of opinion. The 
fact is, I think, that when a rapid effect is required, cold 
applications may be preferred, as the vessels are at once 
emptied. But the reactionary stage will quite surely repro- 
duce the difficulty, possibly in a somewhat exaggerated form. 
Where the emergency is not particularly pressing hot appli- 
cations are to be preferred. The primary effect will be to 
increase the volume of blood in the part, but the stage is of 
short duration, soon succeeded by a diminution in the size of 
the vessels, which is practically a permanent condition, and 
therefore curative. 



VII— SURGICAL REPAIR 

Repair in physiological language, is restoration from mole- 
cular loss or waste. It is something more than this in surgical 
language, it is the attempt to replace lost parts or tissues, to 
till gaps caused by injury or gross lesions. It is of funda- 
mental importance that the surgeon should understand the 
methods of repair, it being a question of daily and hourly 
interest to him. The attempt, on all occasions, that the 
organism makes, is to replace the lost tissue in kind and bulk; 
it is safe to say that it is never fully successful, the bond of 
union, or the new tissue, is at best more or less a caricature 
of that which has been lost. By thoroughly comprehending 
the process, the surgeon is enabled to materially assist the 
natural forces, by suitable medication, to remove all impedi- 
ments from the way; and, furthermore, will be able to select 
the most appropriate treatment in a given case, knowing 
beforehand the manner in which his work will be completed. 

Essential to repair, is a certain amount of irritation, with its 
consequent hyperaemia, care being had to prevent, as far as 
possible, the crossing of the boundary line into inflammation. 
While irritation is so essential to perfect or tj-pical repair, its 
source and character is such that there is constant danger of 
its becoming too energetic for the purpose in hand, and calls 
for restraint far oftener than stimulation. The occurrence of 
an injury is at once a demand for repair, and a cause for its 
establishment. But two stages are clearly marked, varying 
in duration, and some other particulars, with circumstances 
such as extent and kind of injury. The first stage or that of 
passive repair, is one of preparation, or rather elimination. 

F 2 67 



68 ELEMENTS OF SURGICAL PATHOLOGY 

The second, is that of active repair, when germinal elements 
are furnished, and organized into the required tissue. These 
stages require separate consideration. 

First Stage. — The first effect of an injury, such as a wound 
in the soft parts, will be driving back the blood, momentarily, 
with some degree of " local shock." This shock, at times, may 
continue for an appreciable length of time, but is often moment- 
ary; during its continuance function is suspended. Shortly, 
however, comes a reactionary effort, function is exaggerated, 
and the blood which had been driven back, rushes forth with 
unusual violence. Whether the haemorrhage ceases spontane- 
ously, or is arrested by art, the conditions are the same, viz. 9 
a plugging up of the cut extremities cf the vessels. The 
prominence of any one or all of these phenomena, is deter- 
mined by the kind of injury, a smooth cut or a crushing and 
tearing wound, and to the rapidity with which it is inflicted; 
the more rapid the force operating on the wounded tissue, the 
greater the tissue-shock; the smoother the tissues are divided, 
the more profuse the haemorrhage. The first part of this stage 
of repair is occupied by the reaction from shock, and the con- 
trol of haemorrhage. These being accomplished, the remain- 
ing portion is occupied in eliminating from the wound any- 
thing that may prejudice repair. Any foreign material, 
organic or inorganic, will interfere with union, and hence the 
wound must be in a state of true ascepticism before this stage 
can be completed. The stage may be materially shortened by 
the surgeon's care to remove all visible and detachable foreign 
material, and the absolute arrest of haemorrhage; but even 
when all this is done, there is much, in the majority of wounds, 
that escapes the view of the surgeon, and which nature gets 
rid of in her own way. Part of it undergoes change of some 
form, and is absorbed; part of it is liquefied and discharged; 
and part is ''squeezed" out, as it were, unchanged, by the 
gradually increasing tumefaction of the part. This stage is 
completed when the wound is absolutely clean, and the sev- 
ered parts ready for union — yet while this is going on active 
repair is not altogether in abeyance; it is true there is no 



SURGICAL REPAIR 69 

appearance of germinal elements for the new tissue on the 
surface of the wound, but they are accumulating, gathering 

their forces on every side, so that the tissues are tilled, which 
accounts for the tumefaction in part. So, then, it is seen the 
irritation produced by the foreign elements, and that from the 
effort to dispose of them, is essential to call into activity forces 
that shall restore, in more or less perfect fashion, the lost con- 
tinuity. 

Second Stage. — This stage is the one of active repair, in 
which elements of the new tissue to be made up appear on the 
surfaces of the wound, and the capillaries undergo important 
changes to perfect the work. The medium of repair is the 
organic cell, derived in this case, from a multitude of sources. 
Ziegler has shown {Path. Anat.) that each tissue produces 
germinal reparative matter that is peculiar to itself; bone pro- 
duces bone, muscle produces muscle, or something of its own 
type, and of the general design when the organization is com- 
pleted, but never a perfect reproduction. The result is, there 
is a wound which leaves a gap to be filled with new mate- 
rial, involving a number of unlike tissues, as bone, cartilage, 
muscle, nerve, connective-tissue and epithelium — each of them 
furnishes, by proliferation from their cut extremities, cells like 
their own. The blood furnishes numbers of leucocytes, the 
lymphatics likewise, and from this mass of cells, of varying 
origin and destiny, the new tissue is to be made. These cells 
are seen to be disposed in a sheet or film, collectively known 
as lymph or plasma, covering the raw surfaces, becoming 
thicker, by sub-deposition, until the gap is filled up. On 
microscopic examination nothing distinctive or pathognomonic 
is found in these cells; they all look alike, and it is not until 
repair is well inaugurated, that we can detect any attempt at 
differentiation. The connective-tissue cell is predominant, 
being proliferated in greater numbers than, others, and com- 
mencing organization earlier. This proliferation is beyond 
ordinary demands of the organism, and is determined by the 
irritation caused by the infliction of the injur}', the effort at 
elimination, and the h^-percemia consequent upon both. The 



7o ELEMENTS OF SURGICAL PATHOLOGY 

cells are first of the typical spherical shape, later changing 
form, from their original or inherent property, or from the 
nature of surrounding circumstances. The older cells being 
at the top, and center of the cavity, the changes of form are 
first observed there. In studying them from the youngest 
cells upwards, we will note that they first become oval, then 
fusiform, and lastly very slender, with long filiform extremities, 
which become interlaced, or felted together. But the upper 
layer of cells are derived from the epithelium, and are spread 
over the surface, flattened like the epithelium from which 
they are derived. 

If the cells from these various tissues were thrown out with 
equal rapidity, and in proportional numbers, the new tissue 
might be a reproduction of that which was lost. This is not 
the case. The connective-tissue cells are in immense majority, 
and by compression as they organize destroy multitudes of 
cells from other sources. When the new tissue, or scar, is 
completed therefore, the characters are largely those of fibrous 
tissue, a felted network, contractile, of low vascularity, and 
insignificant nerve supply. Notwithstanding the numerical 
preponderance of connective-tissue elements, the chief factor, 
or at least the initial one — is the leucocyte. The leucocyte is 
probably a stimulant to proliferation, in the first instance, and 
formative secondarily. The connective-tissue corpuscle is 
formative only. Occasion will occur later to treat of the 
genesis, function, and destiny of the leucocyte; at this time I 
will assume as a fact, about which I cannot entertain a doubt — 
that the leucocyte is migratory under proper conditions- 
When this occurs, as Cohnheim and others have shown, it 
first stimulates connective-tissue cells to renewed activity, 
and later contributes itself to the resulting organization. A 
certain amount of irritation is necessary to render active this 
genetic property in the white cell. Those white cells which 
appear in the tissues from the extravasated blood, are not at 
all times active; they are often appropriated by the young 
cells, for nutriment, or degenerate into pus cells. So also 
with the lymphoid corpuscles derived from the lymphatics. 



SIUCK'AL KKIWIK 



71 



To act as stimulators to the formative elements, the white cell 
must be in the condition we call •• migrating," out of the blood 
current. This is caused by the irritation accompanying the 
injury, and is thus described by Ziegler (/ c. 150), using the 
term "inflammation." however, where I prefer to use hyper- 
emia: -The factors which cause the inflammatory process 
to take on a formative or constructive character are not 
always the same. We must in general assume that some 
cause is acting which keeps up the morbid alteration in the 
vessel walls, and so gives the inflammation in some degree a 
chronic character. In open wounds the inflammation is kept 
up by contact with the air, with the floating matters suspended 
in it, with the dressings, with the secretions from the surface. 
This continues till the skin, growing over the margin of the 
wound, at length protects the vascular tissue from further 
irritation. In subcutaneous necroses following an acute 
exudative inflammation, the dead tissues, or dead exudations 
are enough to maintain a certain irritation in their neighbor- 
hood, especially as they undergo certain chemical changes 
before they are finally absorbed. In other cases, the original 
cause of injury persists, and continues to excite even fresh 
inflammation; or a new injury may affect a part in which 
inflammation is declining or over-past, and kindle it afresh. 
Which of all these possibilities applies to a given case, is often 
hard to determine. Very frequently several such factors are 
in action, either at the same time or at different stages of the 
process." So much for the sources of the irritation, and the 
consequent germinal elements. Next to claim attention is the 
manner of organization. 

In a former paragraph attention was called to the changing 
shape of the cells. This change is largely due to the inherent 
property of the cell, it is true, but it is also greatly influenced 
by the immediate surroundings. 

A cell has a certain direction given to its growth by the 
form, consistency, and other characters of the parts from which 
it comes, or which it meets. Thus all connective-tissue cor- 
puscles normally develop into the fusiform or - ; spindle-cell." 



72 



ELEMENTS OF SURGICAL PATHOLOGY 



The caudate processes interlace, and as Ziegler (/. c. 154) 
tells us: "they become tightly packed together. This is 
especially noticed in the deeper layers of the granulation-tis- 
sue. When their number has reached a certain point fibrous- 
tissue begins to be produced by the formation of a fibrillated 
intercellular substance. The latter arises in part directly from 
the cell protoplasm, and in part from a homogeneous ground 

substance derived from the fibroblasts 

The run of the fibres is generally in the same 

direction for considerable lengths. When the fibrillar have 
reached a certain degree of definiteness and strength the pro- 
cess of fibrillation ceases, and the remaining cells with their 
nuclei remain as fixed connective-tissue cells. They lie along 
the surface of the fibrous bundles." Some of these fibrillating 
cells, however, develop a bi-caudate extremity, from encoun- 
tering some obstacle to fibrillation; they surround it. There 
are cases in which a cell under similar circumstances, becomes 
multipolar. When this process is complete, the fibrous net- 
work becomes formed cicatricial tissue and the cellular organ- 
ization is finished. 

But there is something yet to be considered. Ail of these 
cells do not remain as component parts of the new tissue. 
Some of them commence to show nuclear division, but with- 
out division of the cell-substance, until they become multi- 
nucleated, giving them a granular appearance. These are the 
■pus cells, to be studied in a later chapter. They are cells " in 
process of decay. The multiplication of the nuclei is evidence 
not of subdivision, but of disintegration." (Ziegler.) The 
same authority tells us that these pus cells are variously dis- 
posed of; some of them are dissolved and absorbed to feed the 
growing cells, some of them remain as a protective covering 
to the delicate new tissue, but the greater number are dis- 
charged as pus, the excess of reparative material. The ques- 
tion must claim attention later in our study, but at this point 
attention may be directed to the importance of observing the 
character of the pus as an index of the process. Thus when 
too profuse it would indicate overproduction and diminished 



SURGICAL REPAIR 73 

organization. When scant}- it shows lack of material; when 
ill conditioned in any way, some defect in repair; when watery 
and acrid, some destructive process; when suppressed, an arrest 
of repair, absorption of septic material, or some active morbid 
process. In a later chapter these conditions will receive full 
attention. While the o-enesis of the cellular elements of the 
new tissue is of such importance and interest, there is still 
another, and equally momentous process going on, one which, 
if absent, would render the attempt at repair abortive. This 
is the vascularization of the new product by development of 
blood-vessels. The growth of blood-vessels into the granula- 
tion-tissue takes place from the capillar}* system entirely, or 
inosculating branches of small vessels, which are little more 
than capillary in size and structure. The cut extremities of 
these minute vessels are closed partly by some degree of intro- 
version of their walls, but chiefly by coagulae, giving a bulb- 
ous appearance, on the surface of the wound. Shortly there 
are buds, or small projections, on the sides of the extremity, 
which later become branches reaching out to meet similar 
branches coming from other vessels in the neighborhood. 
Sometimes the offshoots are tubular from the start; at others 
they are solid protoplasmic C}*linders, which later become tun- 
nelled (vacuolation). From opposite sides of the wounded 
surface, these vessels reach out to meet each other, when 
meeting fusing together. In their growth they meet obstacles, 
of various kinds, which determine a further subdivision, or 
sending off intercellular offshoots, until, reaching out from all 
sides, they gradually meet, join, and a net-work of vessels is 
completed, ramifying in every direction among the elements 
of the forming tissue. The number of vessels being far in 
excess of the usual supply, in territories of similar dimensions, 
determines a greatly increased supply of blood, which is needed 
for the purpose immediately at hand, but which is finally 
reduced to something almost as much below the normal stand- 
ard. 

The separated parts being united, or the gap tilled up, and 
the surface covered with epithelium, the formative process is 



74 ELEMENTS OF SURGICAL PATHOLOGY 

complete. A study of this new tissue shows that it cannot be 
considered a reproduction, there being such an excess of con- 
nective-tissue ; it represents a bond of union, and nothing more. 
The irritation now subsides, the proliferation of cells ceases, 
and we have a highly vascular, sensitive and thinly covered 
tissue, of a darker color than the surrounding parts, somewhat 
elevated also above the surface. The process is not yet com- 
plete ; the normal character of scar-tissue is of low vascularity, 
and defective organization; as we find it at this stage, it is super- 
normal and must undergo some metamorphic process. This is 
secured by contraction, or shrinking which is a common feat- 
ure in all scars, greater under some circumstances than others.. 
Under this action blood-vessels are ''choked "and disappear,, 
nerve fibres atrophy and waste away; the scar becomes flat- 
tened to the level of the surrounding skin, sometimes sinks 
below it, assumes a paler color, even white and colorless, and 
becomes insensitive. Occasionally these changes go too far,, 
under some morbid influence, and the scar is very depressed, 
may even disappear, or take on other and hypertrophic char- 
acters. This will be deferred, however, until a later para- 
graph. In closing this branch of the subject, it will be suffi- 
cient to call attention to the fact that the scar once formed is 
permanent, and while constantly approaching closer and closer 
to the normal type, to the end of life will remain as something 
short of perfect reproduction. It grows with the growth of 
the body, so that, as Paget has said, i; a scar the length of the 
child's little finder, will be that of the man's when he comes to 
adult life." 

We have now taken a rapid review of the facts established 
of surgical repair in general, but have still to give some atten- 
tion to various modifications. Different writers give varying 
methods of repair, but it would seem that the list might con- 
veniently be compressed into four varieties. Immediate union; 
union by first intention; granulation; and under a scab, or 
subcutaneously. 

(a.) Immediate Union is the only form of surgical repair 
in which scar-tissue is not formed. It is a direct adhesion of 



SURGICAL REPAIR 75 

Opposing cut surfaces, without exudation, or any of the ordin- 
ary concomitants of repair. To secure such a desirable 
union, the wound must be smoothly incised, absolutely free 
from foreign material of any kind, closely and accurately 
approximated, and all disturbing influences excluded. There 
is. probably, cell-proliferation, but the fact is difficult to estab- 
lish from the entire absence of a scar; the parts have the same 
appearance they had before wounding. The probabilities are 
that each divided fibre is united by simple fusing. Staphy- 
sagria has long enjoyed the reputation of promoting repair 
such as this: The fact that the minimum of irritation is 
required may be the reason for its indication, from its marked 
power in quieting muscular excitement. I have many times 
secured such union, when the incisions were smoothly made, 
and coaptation perfect; oftener, however, such results were 
only in a part of the wound. 

(£.) Primary union, otherwise union by first intention, is 
the commoner method of repair observed in surgical practice. 
It is in all particulars identical with that already described, 
the typical form of the process, particularly occurring when 
the depth of a wound, or its linear extent is greater than its 
width; that is, in all lesions where parts are divided, but can 
be approximated. The union is secured by binding together 
these divided structures by the interposition of cicatricial 
tissue. As far as mere continuity of an organ is concerned, 
repair is adequate providing the organ has not been com- 
pletely severed; in this case there will be impairment of 
function, transient or permanent, depending upon the nature 
of the part. Thus if a muscle is completely divided, and union 
is of this sort, the action of the muscle is completely destroyed; 
that is full action. The muscular force is designed to be 
exerted from its origin to its insertion; the interposition, 
somewhere between these points, of a scar will transfer the 
insertion of the proximal portion to the scar, and the origin 
of the distal to the same point. Now the contractions are in 
both directions from the scar, and the full utility of the organ 
is lost. The shorter portion sometimes atrophies, and may 



76 ELEMENTS OF SURGICAL PATHOLOGY 

disappear entirely. In the case of nerves the same consider- 
ations obtain, with this differenee- f -that in favorable cases, that 
is where there is not too great dispartition — nerve cells may 
proliferate downwards, and ultimately reestablish communi- 
cation. This, however, is a work of time, and often the 
distal extremity will be found totally destroyed by trophic 
changes, making reservation impossible. Continuity of vas- 
cular supply is secured in two ways. Capillar}^ organization 
is accomplished as already explained. Larger arteries fur- 
nish collateral channels of communication. An artery being 
wounded, and the end inverted or secured by ligature, it 
assumes the general shape of a test-tube. If the bottom of a 
test-tube be filled with sand, and an opening made in the side 
of the tube some distance above the sand, on pouring water 
into the tube it w r ill be seen, by motions in the sand, that the 
stream is divided. One stream passes directly out of the 
opening; the other strikes the bottom of the tube, and is 
thrown, back in a spiral form, churning up the sand with it. 
The same thing occurs in the case of a wounded vessel, with 
this result: the churning motion of the one stream hastens 
or promotes a fibrinous clot in the bottom of the vessel, 
which, when built up to the level of the first opening is pre- 
vented from going higher by the constant passage over it of 
the whole stream of the blood. The clot then commences to 
organize as granulation-tissue has been described, and the col- 
lateral vessel becomes gradually enlarged until the dimensions 
are the same as those of the parent vessel, or sufficiently near 
it to equalize the tension. 

It must not be forgotten that repair is not perfect repro- 
duction. We found that soft tissues united by new fibrous 
tissue possessed very few, if any, of the normal characters. 
That nerve tissue is only incompletely reproduced, and then 
only after long periods of time. Even the new epithelium is 
thin, and depraved. In the case of hard structures, like bone, 
there is a similar state of affairs. Plasma is poured out 
around and between the ends of the fragments, after the 
foreign material has all been removed —an ensheathing or pro- 



SURGICAL REPAIR 77 

visional -callus." as it is called. Afterwards, a definite organ- 
ization, of such portions of it as may be needed, takes place, 
known as permanent or definitive callus, when the provisional 
portion is absorbed. Now on examination of this bond of 
union, it is found to have many of the characters of bone, but 
is much more dense and compact than bone ever normally 
becomes, and so fairly represents the " caricature" of the 
tissue of the part already studied in the case of the soft parts. 
It is precisely the same process as occurs in union by first 
intention in soft parts. Bones may unite by immediate union, 
where there has been no displacement of the fragments, and 
then we find no signs of deterioration in type. The repara- 
tive material, in both cases, however, is derived from the bone 
itself, the osteoblasts, and not from the periosteum, as was 
formerly supposed, whose sole purpose is one of nutrition. 
Remedies play a highly important part in promoting repair by 
this method. In the case of soft parts generally, Calendula is 
to take first rank; it may be given internally, or used topically, 
with a preference for the former, for the following reasons: 
The perfectness of repair must be in direct proportion to the 
supply and utilization of reparative material. Anything which 
adds to the water of the plasma, must naturally dilute it and 
lessen its potency; furthermore, if the application of water is 
liberal, germinal elements will be washed away. If this 
danger is sought to be avoided by using cerates or ointments 
medicated with Calendula, the oily matter will become mixed 
with the corpuscles, separate them, and necessarily prejudice 
their organization. In the case of bones Symphytum will take 
the place of Calendula, but if union is tardy Calearea -phos. is 
to be preferred. 

I have already referred to the indications to be derived from 
a study of the pus. The matter will be referred to later, under 
its proper head (Suppuration) but the following suggestions 
may be appropriate : 

Pus too profuse, normal in character, Iodine. 

Thick, scanty, streaked with blood, Bellad. 

Profuse, green, or bright yellow, Puis. 



78 ELEMENTS OF SURGICAL PATHOLOGY 

Thin, watery, brown, cadaverous odor, Silic. 

Thin, watery, light-colored, viscid, putrid, Graph. 

Thin, watery, lemon-colored, cadaverous odor, Merc. 

Thin, watery, cheesey smell, Sulph. 

Milky, not offensive, Lycof. 

Milky, curdy, Calc carb. 

Thin, dark, bloody, Lack. 

Suppressed, Arsen. 

Smelling like brine, Graph. 

Of course other general indications must be sought for. 

(c.) Union by Second Intention (or, as otherwise known 
by "granulation,") is very similar to the last, but with a some- 
what different, or modified result. There is the same prolif- 
eration of cells, as in the former case, but in place of being 
disposed in a sheet or layer, they are heaped up, showing to 
the naked eye the appearance of a rough, mam millated surface, 
the elevations being composed almost entirely of lymphoid 
cells, around and among them capillaries ramifying, in every 
direction, terminating in loops on the top of these " granu- 
lations," as the elevations are called. The granulations 
gradually increase in size, becoming more and more promi- 
nent, encroaching on each other at their bases, capillary com- 
munication being established on all sides, until, finally, the 
whole cavity is filled with them, reaching above the surround- 
ing level. Such a mode of repair is effected in wounds with 
great dispartition, or when the superficial extent exceeds the 
depth, as in the case of ulcers or wounds with loss of substance. 
As the cells multiply, and the granulations increase in size, 
the deeper or older portions of the mass become firmer and 
compact, taking on the same characters of organization as 
were shown in union by first intention. At the same time, in 
typical cases, the area of the granulating surface is constantly 
diminishing, from proliferation on the sides, and a growth of 
epithelium from the edges. This epithelial growth covers the 
granulations, as they reach above the surface, and when com- 
plete deeper proliferation ceases, but the new tissue is some- 
what elevated above the surrounding parts. Contraction now 



SURGICAL REPAIR 79 

commences, having the effect to reduce the prominence of the 
scar, which in most cases becomes slightly depressed. In 
typical healing by this process, the final closure of the wound 
is from the edges toward the center. A different process, from 
the center toward the edges, does not promise perfect repair; 
in most cases it will not be completed; the wound will break 
open again. 

The remedy of first value in this form of repair is Calendula, 
but defects in this process may call for others. The condition 
is. to all intents and purposes, one of ulceration, and is to be 
treated as such. Accordingly questions of therapeutics will be 
referred to that chapter. The process will be much faciliated, 
it will be observed, if pressure be exerted in such a way that 
the area of the wound will be diminished, and yet not to an 
extent to prejudice vitality. Judicious bandaging and strapping 
will therefore be useful. 

(d.) Healing Under a Scab, or Subcutaneously: — In the 
case of a purely subcutaneous wound, one in which the 
exposure of the wounded surfaces to the air does not occur, 
the process of repair is very nearly the same, as far as results 
are concerned, as when immediate union takes place. The 
same thing occurs in union ;% under a scab," if the crust re- 
mains unbroken to the end. Such wounds are tenotomies, as 
made intentionally, or rupture of tissues, by contusion or other- 
wise, without lesions of the integument. The scab referred to, 
is formed by inspissation of the lymph, mixed often with some 
innoccuous foreign material. Undoubtedly the stimulation of 
the air, in open wounds, has much to do with keeping up the 
degree of irritation necessary to a profuse exudation and cell- 
proliferation. The exclusion of the air, as it occurs, when the 
epithelial layer is deposited, seems to cause a subsidence of this 
proliferating process, and the fact would tend to show that the 
differences, to be noted later, are due to the exclusion of the 
air, with its consequent irritation. There is still another factor 
that may possibly play an important role, namely the capacity 
of the part in which the exudation occurs. The fact will be 
recalled, that when the breach to be closed is filled with granu- 



So ELEMENTS OF SURGICAL PATHOLOGY 

lation-tissue, there is rapid subsidence of the process, as far 
as -production is concerned — even before the epithelial covering- 
is formed. It is more than probable that as soon as the space 
between the divided tissues, in subcutaneous wounds, is filled 
with germinal matter, as well as the looser connective-tissue 
in the neighborhood, the production ceases. The fluid por- 
tions of the lymph are certainly rapidly absorbed, and the 
reparative material is then almost entirely composed of cor- 
puscles in the most favorable condition possible for speedy 
organization. Whatever the process may be, the results are 
vastly different from repair by any other method. In true 
subcutaneous wounds, the new tissue is a more complete 
reproduction of the old, so much so, that in favorable cases no 
difference can be detected between them. In the new tissue 
formed under a scab, there is often an almost entire absence of 
contraction, so that the parts are not disabled,. and few, if any 
adhesions to near structures. The whole matter seems to be 
one of those occurring too frequently in pathology, in which 
the clinical facts stand for our sum-total of knowledge. 

The therapeutic interests are few, and the indications plain 
and unmistakable. The first is to protect the scab, by all 
means, to prevent the admission of air. Should union by first 
or second intention fail, the surgeon might do well to place the 
parts in a condition favorable to scabbing, by the use of col- 
lodion or absorbent cotton, or some other material, that will be 
allowed to remain until spontaneously detached. Topical 
treatment, of all kinds, must be forbidden, and Calendula, or 
other remedies, given internally. Should pus collect under a 
scab, it can be allowed to escape at some accessible point, and 
a study of its character will furnish information as to what is 
going on within. Could healing by this method be assured, it 
would be the first aim of all practitioners. Unfortunately it 
often fails, in meeting all the essential conditions, and repair by 
granulation must be accepted. 

What has now been said gives a fair account of the various 
uncomplicated conditions of surgical repair, but as is too often 
the case, there are numerous obstacles to success; there are 



SURGICAL REPAIR 81 

many defects, trophic and specific in character, that must not 
fail to receive attention. Defects are of two general kinds, 
the one relating to the process, the other to its results. That 
is there may be a failure to unite, or union having taken place, 
the new tissue is inadequate. 

Failure to Unite, an absence or feebleness of the repar- 
ative process, may be active or passive. It is the latter when 
the individual is old. or enfeebled in any way. It is the former 
when the existence of some morbid action, acute or chronic 
simulates the conditions of senility. It goes without saving 
that the organism cannot, as a rule, carry on two important 
processes at the same time, with perfect success in both direc- 
tions. Under the influence of acute disease, the whole pow r ers 
of the bodv are concentrated on the single vital task of resist- 
ing its encroachments and repairing its ravages. Under these 
circumstances a call for surgical repair cannot be fully met, 
from the simple fact that there is little or nothing to meet it 
with; every such demand must, in the nature of things, borrow r 
from the forces operating elsewhere, thereby at once enfeeb- 
ling those going on for the general good, and inadequately 
furnishing help to the special emergency. In surgical practice 
this condition of affairs is unhappily often met, and seriously 
compromises results in the best managed cases. Should the 
malady be a chronic one, the condition of the organism repre- 
sents that of senility, a condition fatal to successful or speedy 
repair. If the malady is specific, perfect success is impossible 
from the poor quality of the reparative material. There are, 
therefore, very many contingencies met in actual practice that 
can scarcely fail to prejudice typical repair. There is one, how- 
ever, the most potent in point of frequency, namely the occur- 
rence of inflammation. Repair is at once arrested when acute 
inflammation occurs, and it is this fact which prompts me to 
discard the word entirely in speaking of processes so purely 
physiological. In normal repair there is nothing of a patho- 
logical character; it is a simple exaggeration of an ordinary 
physiological process, continually going on in the life of the 
organism, although the waste consequent thereupon might 
possibly give it a semi-pathological character. 



82 ELEMENTS OF SURGICAL PATHOLOGY 

Defects in Scarring, represent, in most cases, a plus or 
minus in the process of repair, due for the most part to acci- 
dental conditions. A scar may be weak, showing a tendency 
to reopen on slight provocation, which would argue some 
feebleness in the reparative process. Such a condition must 
be met by a remedy indicated by the general condition. 
Probably in the absence of particular indications, Calc card. 
oftener meets the emergency. Syphilis, scorbutis, and tuber- 
culosis frequently cause the reopening of wounds long healed, 
or even the disunion of old fractures. Mercurius, lime juice, 
or some clearly indicated remedy must be relied upon to repair 
the damage. Very often the retention in the wound of some 
foreign material, as small splinters of bone, or fragments of 
gun-shot, will cause repeated openings of healed wounds. The 
indication is plain to remove such material if it can be reached. 

A scar may be too thick, hypertrophic, and while otherwise 
well formed be an annoyance from its unsightliness, or may 
even impair usefulness. In cases of sufficient magnitude, such 
blemishes may be shaved off, dissected out, or subjected to 
svstematic pressure by straps or elastic collodion. Up to the 
present I have not found any remedy to give satisfaction, or 
even to produce any effect whatever. 

A scar may again be too thin] as it is called, the epithelial 
covering being delicate, and liable to be rubbed off, or 
abraded. Such cases have always promptly improved under 
Oxalic acid 30* . When bluish in color, and likewise easily 
becoming excoriated, Muriatic acid, in the same attenuation 
has given good results. 

There ma)* be deep attachments of a cicatrix, to bone, fascia, 
or muscle that seriously impairs the utility of a part. In such 
cases Silicea will rarely fail to loosen them up. 

A scar may be depressed, the contraction being too vigor- 
ous. Such cases have been improved by Silicea very notably. 

Ulceration of a scar is due to some general constitutional 
defect, and must be met by some remedy indicated by the 
general condition. Perhaps Mercurms will be oftener called 
for than any other. There yet remain two marked defects in 



SURGICAL REPAIR 83 

cicatrization, about which little is known beyond their clinical 
features; scarring from burns, and keloid. 

Scarring from Burns, almost uniformly presents the most 
exaggerated tendency to contraction. When large surfaces 
are involved the greatest deformity occasionally is observed; 
large joints are dislocated by the contraction, near parts firmly 
united, and the like. The causes for this peculiar contractility 
have never been satisfactorilv explained. Possibly, as some 
have surmised, the action of heat on parts adjacent to those 
actually burned mav be responsible, but no explanation of 
these effects is obtainable. Therapeutically they are of interest 
to the operating surgeon, but the subject is not pertinent to 
the present work. In contractions of minor degree, tension 
and SiJicea have given good results in a number of instances. 
The probabilities are that in the graver forms nothing but 
operative measures will be of any avail. 

Keloid (otherwise C keloid) is a growth that is sometimes 
found in scars, for some reason more commonly in the Negro 
race. They may be single, more often multiple, and so mark- 
edly of the tumor character that the further consideration 
of the subject must be postponed to the appropriate chapter. 

We have now completed a rapid survey of the conditions 
necessary to be understood before taking up the subject of 
surgical pathology proper. The processes are more closely 
related to physiology than pathology, but derive their import- 
ance, to the surgeon, from the fact of their intimate relation 
to the latter as much through the possibility of becoming in 
themselves pathological as to their agency in repairing the 
results of morbid action. 

G 2 



VIII— INFLAMMATION 

Inflammation is a word of uncertain derivation, which has 
been used from the earliest periods as denotive of a condition 
of abnormal heat; in all languages, ancient and modern, some 
form of word has been used signifying "fire" or "flame." 
So, to-day, we understand it to express a condition of increased 
heat, waste of tissue, and pseudo-growth, secondary upon 
hyperemia, and that sustains a relation to surgery similar to 
that of fever to medical practice; indeed, fever is an accom- 
paniment of inflammation, but inflammation is not present in 
all cases of fever. Next to fever there is no process in the 
whole catalogue of morbid action that enters oftener into the 
semeiology of disease; it is found preceding, accompanying, 
or following every surgical affection, and in many ways plays 
such an important part in matters of prognosis and diagnosis, 
that its consideration is very properly placed at the very- 
threshold of surgical study. 

The limits of a work like that upon which we are now 
engaged, are altogether too restricted to treat a topic of this 
magnitude with any degree of thoroughness; at most we can 
only take up the salient features, and the results of experi- 
ment, referring those who desire minute analysis, and to draw 
their own conclusions from inductive studies, to the numerous 
systematic works, and the laboratory. Indeed, this is the 
province of the text-book, on matters of science, particularly 
when treating of topics falling more or less within the domain 
of the recognized specialties. It is impossible for the active 
practitioner to read and study all the conflicting theories of the 
day, weigh the relative value of experiments, and determine 

8 4 



INFLAMMATION 



8S 



the credibility of witnesses. Such work falls more properly 

within the province of the special student, whose opportunities, 
both of practice and reading, peculiarly lit him for the task. 

Some of the more prominent symptoms of inflammation 
are common to hyperaemia, and formerly led to much con- 
fusion among pathologists; in fact the majority of our text- 
books to-day speak of " adhesive" inflammation, when active 
hyperaemia is meant. Inflammation is always pathological, 
destructive in the sense that structural modifications impair 
function. Hyperaemia, on the other hand, is oftener physiolog- 
ical, as it is an essential element in repair, and accompani- 
ment of functional activity. There is still another reason 
why this term "adhesive inflammation" should be discarded. 
The products of inflammation, under ordinary conditions, pass 
away with the cessation of the process. A plastic exudation 
rarely undergoes permanent organization, as does scar-tissue. 

The older pathologists taught that inflammation consisted in 
the establishment of four symptoms, or groups of symptoms, 
viz., heat, pain, redness, and swelling. Their facilities for 
studying vital processes were too limited to enable them to cor- 
rectly interpret even these cardinal symptoms, and they had no 
knowledge beyond them. Limiting the semeiology in this 
way, was the reason why no distinction was made between 
repair and waste. Even at this day, when the microscopist 
and chemist are throwing light into the dark corners of nature, 
making familiar as household words, man)' of the former 
;; mysteries" of life, the student is often misled in the apprecia- 
tion of what he sees. The symptoms of inflammation he often 
considers the process itself; the tumor is viewed as the con- 
crete tangible disease. Now it must ever be borne in mind, 
that in all manifestations of morbid action, and perhaps the 
causes as well, we see only the results of the process, not the 
process itself. Thus inflammation is a chemico-pathological 
process; the symptoms by which it is recognized are not the 
inflammation, nor do they produce it. They are simple conse- 
quences of the disease, its expression, evidences of its estab- 
lishment. We will consider inflammation under two heads: 



86 ELEMENTS OF SURGICAL PATHOLOGY 

the acute and the chronic, inasmuch as there are radical differ- 
ences in the two forms. 

ACUTE INFLAMMATION. 

In studying this topic systematically, we must first consider 
diagnosis, which is largely dependent upon the four so-called 
"classical" symptoms; next the pathology and etiology; glanc- 
ing, finally, at the special therapeutics. 

Diagnosis: — One or more of the common symptoms of 
inflammation may, and do, exist in hyperemia and irritation ; to 
constitute true inflammation, however, all the symptoms must 
occur. As far as diagnosis is concerned, there is no single 
symptom that can be accepted as conclusive evidence; it 
requires all of them, but there may be much variation as to 
degree. From the earliest periods down to the present, diag- 
nostic symptoms have been arranged in two groups, an objec- 
tive, and a subjective, including four prominent conditions. 
The subjective are, heat and pain; the objective, redness and 
swelling. The terms, however, do not at all times represent 
the -state of affairs in a given case, with the exception of heat, 
which is always present — the pain, redness and swelling being 
materially modified under certain conditions. We will con- 
sider each of these symptoms separately, commencing with the 
objective group. 

Redness: — An inflamed part undergoes changes in color 
from various circumstances, which will be more particularly 
described when we come to speak of the pathology. The first 
of these is the increased amount of blood in the part. When 
the part is superficial, the change in color is more pronounced 
than when it is situated deeper. The exact shade of red will 
depend upon the texture of the part, the degree of tension in 
the vessels, the speed of the circulation, and the natural color 
of the tissues. When the parts are very near the surface, and 
the integumentary covering is thin and more or less trans- 
parent, the redness is pronounced. It is modified greatly by 
the vascularity of the part. For instance, in an inflamed cor- 
nea, where the vessels capable of carrying red blood termin- 



ACUTE INFLAMMATION 87 

ate just within the circumference, the more central parts of the 
tissue are cloudy and milky from the spaces being crowded 
with the plasma, with few, if any red blood-cells. Again, 
when the skin is unusually dark, as in the case of negroes, the 
redness is not apparent, but there is a greater intensity of 
color, a deeper shade. When the tension in the vessels is not 
extreme, and the current of the blood is swift, the redness will 
be bright; if the tension is considerable, and the velocity 
diminished, the tint is darker. In these many ways the shade 
of red is modified, but there are still other conditions that 
determine the color. Red is more pronounced in proportion 
as the part is naturally colorless or white. When the natural 
color of the part is other than white, the color resulting from 
the injection of an unusual amount of blood, will be a shade 
that would be produced by a mixture of red and the existing 
color; a blue iris, when inflamed, would not be red, but pur- 
ple. Thus we find that the intensity or vividness of the red, 
will depend upon the degree of tension in the vessels, and the 
rapidity of the blood current, together with the transparency 
of the parts. When the parts inflamed are colored, redness 
will not be produced, but a shade determined by the color of 
the part. Therefore the equivalent for redness is discoloration. 
The tension may be so extreme, that the vessels are rup- 
tured. The blood is thereby poured out into the tissues, and 
the coloring matters may permanently stain them. With a 
high degree of tension, short of laceration, there will be such 
an exudation of serum in loose textures, that the intensity of 
the red color is lessened by a practical dilution. There are 
certain characters to the redness that are constant and diag- 
nostic, however it is produced, and whatever modifications 
there may be. Thus the redness shades off into the surround- 
ing tissues, not terminating abruptly, as is the case in ery- 
sipelas and extravasation. On pressure with the finger, forc- 
ing the blood out of the part pressed upon, it becomes white, 
the redness returning in a sort of wave when the pressure is 
removed. When there is an extravasation of blood, as from 
rupture of a vessel, the color is unchanged by pressure; there- 



8S ELEMENTS OF SURGICAL PATHOLOGY 

fore in cases of inflammation with such extravasation the appli- 
cation of pressure gives somewhat negative results. Fortu- 
nately, however., as far as diagnosis is concerned, redness is 
not the only symptom of inflammation. 

Swelling: — With the exception of heat, the most interesting 
and complex of the symptoms of inflammation is unquestion- 
ably swelling. The causes are threefold, viz.. exudation, 
increase of blood in the part, and actual tissue-growth. That 
increased amount of blood in the part, from an actual increase 
of the contents of the affected territory — -causes some degree 
of swelling, is self-evident; as one of the causes of swelling, it 
is of the least importance. Exudation is, perhaps the most 
important of these, occurring to a greater or less extent in 
every case of inflammation. The characters of the exudate 
depend entirely upon the degree of tension in the vessels. In 
normal degrees of tension there is no exudation. A slight 
increase, as would occur when larger quantities of blood are 
forced into a part than it can easily provide exit for. would 
give a serous exudate, a loss from the blood of the watery 
portion. With still greater tension, the exudate would be 
albuminous or fibrinous, giving false membranes, as in croup 
and diphtheria. The maximum tension, would induce rupture 
of the vessels, and consequent extravasation of the blood. As 
far as exudation is concerned in the production of swelling, the 
character of the part will determine its degree. Thus in loose 
textures, or those of an elastic or distensible character, the 
swelling will be extreme. When the inflammation occurs on a 
free surface, as the intestines or mucous passages, the swelling 
will be little, but the exudation will stand as an equivalent. In 
dense, inelastic tissues, as bone or cartilage, there will be 
increased density, with little increase in size. Hence we may 
say, there is swelling or ///creased exudation. 

But exudation is not the only cause for swelling in inflam- 
mation; in fact it is questionable if it is even the chief cause. 
In all inflammatory exudates we find white blood-corpuscles, 
which, among other properties, stimulates "formed" or con- 
nective-tissue corpuscles into renewed activity, inducing in 



ACUTE [NFLAMMATION 89 

them a return to embryonic conditions. There is thus an 
actual tissue growth of the inflamed part, but fortunately, not 

of a durable character; with the subsidence of the inflamma- 
tion its products pass away, as a rule, in some instances a 
dyscrasia or diathesis will have the effect to perpetuate these 
products, tumors or plastic adhesions being- the result. 

Pain.— The causes of pain are not hard to rind. Dr. 
Roberts Bartiiolow says : " Several elements enter into the 
composition of pain — the peripheral irritation, the transmission 
of the impression to the centre, and its realization bv con- 
sciousness." Thus we see, with an identical irritation, in two 
individuals, the degree of pain experienced will be propor- 
tionate to the receptivity, or acuteness of perception in each. 
The pain has less relation, therefore, to the kind or intensity 
of the irritant, than it has to the individual's capacity for feeling. 
Next will come the nervous supply of the part, the pain being 
greater in proportion as the part is more or less liberally sup- 
plied with sensory filaments. To some extent the function of 
a part will modify pain. In fact, in some instances, there may 
be no pain at all. simply perversion of function. Thus gastritis 
may be almost painless, vomiting becoming its equivalent. 
So in some forms of cystitis, '-spirting of urine" will occur. 
It has been well said that pain is a simple excess of pleasure . 
For example, a warm fire is pleasant on a cold day; to 
increase the heat, as by placing the body in the flame, would 
cause pain. A sound, pleasant in itself, may be prolonged or 
increased in intensity until it becomes painful. A normal eye 
finds sun light grateful, but an intense glare of reflected light, 
or prolonged looking at the sun, may not only cause pain, but 
an actual structural lesion. We may thus consider pain to be 
the result of an unduly prolonged irritation, perhaps normal 
in character, or one of unusual intensity, its actual degree 
being determined by the sensibility of the individual. Later 
in the case, howevever, there are additional causes for pain. 
The increasing swelling or density, by compressing nerve 
filaments, causes pain. Later, the nerves themselves, partake 
in the inflammatory action, and an exudation from the neuri- 



9° 



ELEMENTS OP SURGICAL PATHOLOGY 



lemma occurs inwards, which causes compression of the axial 
matter. * Should this compression become extreme, nerve con- 
duction may be destroyed, and all pain cease. Hence the 
character of the tissue will very greatly modify the degree, 
and the kind of pain. In dense inelastic tissues the pain will 
be greater than in elastic or distensible ones. On free sur- 
faces it may not amount to a pain at all, as in some forms of 
cuticular inflammation; it may be a mere smarting or stinging. 
We find, accordingly, that pain, as with redness and swelling, 
has an equivalent, viz., increased sensibility. 

Heat. — Heat cannot properlv be placed in either the sub- 
jective or objective groups of symptoms entirely, for it is as 
much one as the other. The touch and the thermometer give 
us more accurate information as to the degree of heat than 
the sensations of the patient, and thus it might be more proper 
to consider the symptom more essentially objective. It would 
seem that heat was also particularly diagnostic of inflamma- 
tion, inasmuch as it is a constant symptom, and one without 
an equivalent. Its importance as a symptom being so marked, 
it is to be regretted that there is so much uncertainty in 
regard to its origin. Surgical teachers are much divided on 
this subject, other considerations than those growing out of a 
study of physics requiring attention. Some consider the 
elevation of temperature to be due entirely to oxygenation; 
others to increased vital effort; still others to chemico-path- 
ological changes; and a few that it is material, and gradually 
diffused throughout the body by material contagion. 

The more prominent facts in the case are about as follows: 
immediately upon the establishment of inflammatory action, 
in the stage of "passive congestion," the local temperature 
will rise. The rise may be all the way from one to ten 
degrees (F.), the extent of the rise at once marking the 
intensity of the process, and warning of the danger that may 
obtain from a fall, which is often proportionate to the rise. 
Shortly the outgoing blood will be found much warmer than 
the incoming; next the blood in the affected member will be 
of higher temperature; soon the whole of that side of the 



AtVTK INFLAMMATION 



91 



body partakes in the elevation, and finally the entire volume 
of blood is heated. Of course the passage of blood through 
an inflamed part will raise the temperature, and when the 
whole circulation becomes quickened, as always occurs in 
inflammation of any degree of intensity, it will require very 
little time to heat the whole volume of the blood. The ques- 
tion is therefore narrowed down to the cause of the increased 
heat in the beginning. 

It is impossible to give even a summary of the numerous 
experiments that have been made to determine this point. I 
must rest content to give the results, as they appear to me, 
somewhat justified by own feeble attempts to solve what must 
remain a difficult problem. 

As will be seen when we reach the pathology of inflamma- 
tion, there are live physical states of much value in this con- 
nection. 

First. — There will be an increased amount of blood in 
the part. 

Second. — The rapidity of the current will be notably greater 
than normal. 

Third. — Stasis is the culmination of the process, with a 
great accumulation of oxygen-carriers (the red blood-cells) at 
the focus of inflammation. 

These three conditions indisputably furnish the conditions 
for oxygenation. 

Fourth. — AVandering leucocytes are found in the tissues, 
which determine increased vital effort, also associated with 
tissue-waste in certain proportion. 

Fifth. — There will be fever, with the characteristic excre- 
tion of urea, and other evidences of tissue-loss. 

Now these are the chief of the established facts, and 
whether we call the result oxygenation, or what not, the facts 
remain, and serve to prove that organic elements are con- 
sumed, and the elevated temperature is due, as Simon puts it, 
to a state of * ; active calorification" by material contagion. In 
support of this view. Bryant {Pract. of Surg., p. 28), quot- 
ing in part from Montgomery, speaks as follows: "Either 



g 2 ELEMENTS OF SURGICAL PATHOLOGY 

continuously during the intensity of feverishness, or else more 
abruptly when feverishness begins to subside, there can com- 
monly be traced in the excretion an excess, more or less con- 
considerable, of these nitrogenized, sulphurized and phos- 
phorized products which emanate from textural and humoral 

waste And that febrile excretions 

do, as a rule, undoubtedly attest increased devitalization of 
bodily material." 

The constant symptoms of inflammation may now be tabu- 
latee as follows: 

Pain, or increased sensibility. 

Redness, or increased blood-supply. 

Swelling, or increased secretion. 

Heat always, without equivalent. 

The above, however, are chiefly local, and rarely exist with- 
out constitutional or general disturbances, which are not at all 
surgical in character, being common to many forms of morbid 
action. They vary in different cases, as regards intensity, 
and perhaps, to some extent, in the order of their appear- 
ances, but for the most part appear as follows : When mucous 
surfaces, particularly from central causes, are affected, the 
first symptom will usually be an arrest of the natural secre- 
tions, with a feeling of dryness, both subjective and objective. 
A familiar example is the feeling of dryness and scraping in 
the throat on "taking cold." This sensation is due to many 
causes, most of them unexplainable; primarily there is cap- 
illary hyperemia, which, for a time, arrests or prevents secre- 
tion. Later, there will be an exaggeration of the secretions, 
often not until resolution commences; the excretion being- 
very abundant, at first mucous or muco-purulent, depending 
upon the intensity of the process, later becoming more 
albuminous and less purulent, as well as diminishing in 
quantity, as the morbid action subsides. In cases in which 
the inflammation is high, and the course is rapid, we find 
these three well marked stages; first suppression, second 
excitement, and lastly exhaustion. Upon the full establish- 
ment of the inflammation, fever will occur, its intensity 



PATHOLOGY OP INFLAMMATION 93 

directly related to the intensity of the inflammation; readily 
traceable to the increased heat of the whole volume of the 
blood. The general symptoms, therefore, are not at all sur- 
gical in character, and need not detain us longer. 

PATHOLOGY. 

A study of the pathology of acute inflammation shows that 
the process is essentially a condition of exaggerated production, 
with deficient or arrested organization. These results are 
dependent upon changes in the blood-vessels, with disturbances 
of circulation growing out of them, together with alterations 
in the character and composition of the blood, not entirely 
related thereto. The changes in the blood-vessels are with 
reference to tonicity, size, and capacity. The changes in the 
circulation are temporary arrest, increased rapidity, and final 
stasis more or less complete. The changes in the blood are 
increased fibrin, increase of white corpuscles, and loss of fluid 
elements. That we may have a clear understanding of the 
causes operating to produce these changes, let us review the 
physiology of the blood. In the chapter on hyperaemia some- 
thing was said on this topic, but we have now reached a point 
where the subject must be more carefully considered, as the 
exact line of demarcation between hyperaemia and inflamma- 
tion must be sought. 

The blood, as is well known, carries nutriment to the 
tissues through which it circulates, to some extent removes 
effete material, and acts as a functional stimulant to the 
parts it supplies. To fulfill these varied indications it must 
possess equally varied physical characteristics; it must possess 
fluidity, and carry in its current material from which tissue is 
formed, in whole or in part, as well as some stimulating 
principle. We find it, accordingly, composed of fluid, semi- 
solid, and solid constituents, each with distinct functions. The 
fluid portion is the serum, which acting as a vehicle for the 
others, carries, in addition, in a state of suspension, the saline 
elements, which are not discoverable until they are separated 
or precipitated therefrom. The semi-solid portions are the 



94 ELEMENTS OF SURGICAL PATHOLOGY 

albuminous elements, or fibrine, which have been variously 
considered tissue-forming, and excrementitious. Simon and 
Callender teach it represents post-perfection; that it is 
material which has outlived its tissue-forming destiny, and is 
either eliminated through the lymphatics or reconverted into 
plasma. In other words, it is the excess of plasma, the waste; 
that portion which is not needed for ordinary repair. We 
are familiar from our recent study of hyperaemia, with the 
fact that stasis or interruption of the current of the blood, will 
greatly increase its fibrinous character. But this fact may be 
accounted for in other ways than a supposed post-perfection. 
The latest teaching does not sustain the assertion of Simon 
and Callender quoted above. Fibrine does not exist in the 
blood under normal conditions. A coagulable albuminoid 
element called fibrinogen is found, constituting about three 
per cent, of the plasma, which under certain conditions does 
become organized into the contracting filamentous substance 
which we call fibrine. The conditions determining this coagu- 
lation are variously estimated by different observers; some 
assume that the paraglobulin of the red cells, acts as a ferment, 
determining the coagulation or solidification of the fibrinogen; 
hence this substance is sometimes called " fibrinoplastin." It 
is essential to the process that there should be an arrest of the 
circulation in the part, such as occurs in inflammation, or some 
lesion of the coats of the vessels. It should be observed, 
before going further, that the quantity of fibrinogen is not uni- 
form throughout the whole volume of the blood. It is, as 
Cleland {Animal Physiology, p. no) says: "not easy to de- 
termine the measure of its variation; but there is one circum- 
stance which makes it seem probable that the fibrine is not 
used for the manufacture of tissue, but is a product resulting 
from the changes effected in the blood by circulating among 
the tissues; and that is, that the blood emerging from the 
liver, after being subjected to the action of that organ, is no 
longer spontaneously coagulable, and only yields a small 
amount of fibrine after violent whipping with rods (Beclard) ." 
So far the evidence is in favor of the excrementitious char- 



PATHOLOGY OF INFLAMMATION 95 

acter of fibrine, but evidence on the other side is abundant, and 
mav be considered to represent later views, based upon more 
extended observation. Dai.ton [Physiology* p. 82) says: '-If 
pure fibrinogen, in a dilute saline solution, be coagulated by 
heat, the quantity of coagulum so obtained is as great as that 
produced by coagulation by action of the ferment (Frederics) . 
This shows that the spontaneous coagulation of fibrinogen in 
the blood does not depend upon its union with another sub- 
stance, but that it is simply a change of molecular condition, 
like that which occurs in other coagulable substance." Next 
comes Hayem, who finds that the granular bodies found in the 
blood, are destined to become red blood-cells, and he has given 
them the name of "haematoblasts," on this account. Andral 
sugposed them to be fibrine, and found them to have filaments 
added at the moment of coagulation. Finally Ranyier says: 
••These angular granulations which exist in the blood, are little 
masses of fibrine, and they become the centers of coagulation, 
as a crystal of sulphate of sodium placed in a solution of the 
same salt becomes the center of crystallization." The experi- 
ments of Hayem go far to prove the proposition of Ran- 
vier, as he has found the hcematoblasts to be the foundation 
for coagulation as it occurs in spontaneous arrest of hemor- 
rhage from cut veins. This discussion is of interest to the 
surgical pathologist, inasmuch, as will appear later, a prime 
condition of inflammation is increased fibriniferousness of the 
blood. We have learned at least that heat and arrest of the 
circulation produce coagulation, and we must determine 
whether these conditions are furnished prior to the establish- 
ment of inflammation, or later. In other words, are they 
causes or effects? For the present we can pass to other con- 
siderations. 

The solid portions of the blood are the red and white cor- 
puscles. The former of these are assumed to be simple car- 
riers of oxygen, but the mode of production, and final disposi- 
tion, are still in dispute. Accepting the theory that they are 
chiefly concerned in carrying oxygen, we, as surgical patholo- 
gists, are not further interested in the controversy. 



9 6 ELEMENTS OF SURGICAL PATHOLOGY 

The white cell is variously spoken of as the leucocyte 
bioplast, lymphoid-corpuscle, etc., all expressing the same 
idea, that it is protoplasmic, an essential factor in formative 
processes. The origin, function, and destiny of this body are 
well understood, so that the study forms a very interesting 
chapter in vital processes. It is proper to enter upon this 
topic at this time, as preliminary to some later considerations. 

Among the lower forms of organisms, the infusoria, we find 
one, of the most simple construction, purely protoplasmic, or 
bioplastic without demonstrable organs or parts: a homoge- 
neous mass of albuminous matter. It has power of locomo- 
tion, by thrusting out portions of its substance, pseudo-poda 
( ;i false-feet"), and projecting the body into them. At times 
the movements are quite rapid, and cause constant changes in 
form w T hen viewed under the microscope. This changeable- 
ness in form has led microscopists to name it the "amoeba." 
from the Greek, signifying -change." Now as far as our 
means of observation extends, the white blood-cell is a veritable 
amoeba, and moves about in the current of the blood, and in 
the tissues into which it finds its way, independently: it almost 
seems to be occupied in furtherance of design. Its peculiar 
function is two-fold, so far as it is of surgical interest, viz., to 
stimulate growth and reproduction in cells, by conveying to 
them a stimulus perhaps not originating within itself; and pos- 
sibly to form tissue, by duplication of itself, precisely as all 
cellular organization is carried on. 

Now the white cells, or leucocytes, are born in the lym- 
phatics and i; blood-glands," leaving there with few elements 
of life in themselves, circulating in the blood as idle formative 
material, until they reach the lungs. They enter the lungs 
through the pulmonary artery, ordinary plastic matter: they 
emerge from them in the pulmonary vein, living bodies, capa- 
ble of continuing their life and functions, under favorable cir- 
cumstances, outside of the body. We shall have frequent 
occasion to study the manner in which they convey both nor- 
mal and abnormal influences to other parts of the body, but 
at present are only concerned in two properties. First they 



PATHOLOGY QP INFLAMMATION 



97 



Stimulate renewed growth and reduplication in formed cells, 
with which they come into contact, after leaving the blood- 
vessels. Second, thev probably multiply themselves and form 
new tissue, becoming ••formed" or " connective-tissue " cells, 
which, in the case of inflammation, is often as short-lived as 
the process is hyper-natural, this accounting for the pseudo- 
growth as a characteristic of the swelling. Later I shall have 
occasion to speak of the mode of transit of the leucocyte from 
the vessel; at present this is sufficient. The escape of the 
rluids into the tissues, through the walls of the vessel, salts, 
albumen, and red-corpuscles, is accomplished by forces entirely 
outside of themselves; that is, they escape by transudation, or 
extravasation due to intra-vascular tension from the crowding 
into the vessels of an unusual amount of blood. One of these 
elements escapes with greater ease than another, under differ- 
ent degrees of pressure, not from any vital peculiarity, but 
simply bv their differing ability, in point of fluidity, form, or 
dimensions to pass through the walls of the vessel. In the 
case of the leucocyte, however, the escape is arcomplished in 
a very different manner. This will be shown later. 

This review of the composition of the blood includes only 
that which is of value or interest in the present connection. 
We must, with like brevity\ recall some of the facts relating 
to the circulation of this -fluid-tissue." 

When speaking of hyperemia, it will be remembered, it 
was said that the circulation of the blood was carried on by 
the combined agencies of the heart's action the muscular con- 
tractility of the arteries, the pressure of surrounding muscles, 
and the action of gravity. Possibly capi.\ary attraction may 
operate in some places. The normal action of each of these 
agencies secures a normal circulation; any excess of action in 
one direction, or lowering of vigor in another, must modify 
the whole function. The changes in the circulation, in the 
commencement of inflammation, are confined to a somewhat 
restricted territory, and may be abortive. At present, how- 
ever, we are solely occupied with those which go bevond a 
mere hyperemia. As to the vessels themselves, the primary 

II 



p8 ELEMENTS OP SURGICAL PATHOLOGY 

change observed is in capacity, either dilatation or constric- 
tion, beyond what is usual in ordinary conditions, both as to 
extent, and continuance. The dilatation of a vessel is wholly 
due to the tension from the blood forced into it: it is purely a 
passive act. The reactionary contraction is produced by the 
action of the middle or muscular tissue, its energy being 
derived from the vaso-motor system of nerves. There is 
very much confusion in our text-books as to the origin and 
distribution of these nerves. Some assign them a cerebro- 
spinal origin, and look for their roots in the medulla, and 
cervical spine. Others consider them ganglionic and suppose 
them to be in relation to the cardiac ganglia. Others again, 
esteem them to be derived from both systems, assuming them 
to be partly inhibitory, and partly excito-motor. Dalton 
(Physiol., 1881, p. 104) says: "The real origin of the vaso- 
motor fibres of the sympathetic is in the spinal cord. All the 
sympathetic ganglia, besides their connection with each other 
by the longitudinal filament of the sympathetic nerve, are con- 
nected with the adjacent spinal nerves by communicating 
branches; and many of the fibres composing these branches 
may be traced through the spinal nerve roots, to the spinal 
cord. Furthermore, experiment also shows that the spinal 
cord is the source of nervous action for the sympathetic 
system." As to their double function there can be little 
doubt, and it is possible their double character extends to the 
point of origin. A recent writer (Stricker) affirms that 
they are even in two distinct sets, a vaso-dilator, and a vaso- 
constrictor; if he is correct, which is not certain — this is the 
only occasion in animal physiology when a tubular organ 
dilates in any other manner than from a cessation of vital con- 
striction, or an intra-tubular pressure from unusual injection. 
There is little doubt in my mind that dilatation, during normal 
circulation, is solely due to the entrance of blood into the 
vessels; contraction is produced by the contraction of the 
muscular coat, in part from the continued nervous stimulus 
though the vaso-motors, and in part from the irritation of 
the muscular fibres from the former distension; the resiliency 



PATHOLOGY OP INFLAMMATION 99 

of the vessel, in other words. For some time I have been 
of the opinion, that if the muscular tissue of an artery 
represents a continuity of the muscular fibres of the heart, 
the vessels are inherently irritable in common with the heart. 
Latelv some corroborative testimony has been furnished. 
The New York Medical Times (July, 1882, p. 121), in giving 
a report q£ the recent meeting of the American Institute of 
Homoeopathy reports an abstract of a paper by Dr. Wm. 
Owens on t; The Origin of Vaso-Motor Nerves." in which it 
is said: ; ' On the other hand, the author of the paper then 
affirms that there must be another vaso-motor center" (than 
the medulla and portion of the cortex-cerebri), "and searches 
for it in the solar plexus or center of the sympathetic (organic) 
system of nerves, and quotes Romley, Volkman, Schiff, 
Goltz, Mueller, Marshall-Hall, Bidder, Burden- 
Sanderson. Ross and others, to sustain this opinion, and shows 
that all the functions of the circulation are under the control 
of this system of nerves, and that many of the organs may and 
do act independently of the brain, medulla or spinal cord, and 
refers to the lower orders of animals to sustain this showing, 
and that they have as perfect a circulation without a brain, 
medulla or spinal cord as the higher animals and man have 
with such organs." Every student is familiar with experi- 
ments made on the hearts of cats and frogs, showing how, 
when cut into a number of pieces, each will respond to irrita- 
tion. This inherent automatic nervous energy, which exists 
at the centre of circulation, extends throughout the domain of 
the vascular system. Like other ganglionic arrangements the 
energy may be reinforced, here and there, but the original 
scource is at the centre of its functional life. 

The first symptom of approaching inflammation, patholog- 
ically, is a contraction or dilatation of the vessels, or system 
of vessels under observation. An irritant being applied to the 
surface, there is a tetanic spasmodic contraction of the mus- 
cular coat, leaving the fibres exhausted or momentarily par- 
alyzed, which causes increased dilatation in two ways. First, 
by loss of tonicity the vessel becomes enlarged; second, by 

H 2 



IO o ELEMENTS OE SCRGICAL PATHOLOGY 

ceasing to assist in the propulsion of the blood, a larger 
amount is admitted, and the tension is greatly increased. 
Should the irritant, however, expend its action on the centers, 
as might be the case in morbid action, the peripheral primary 
indication would be dilatation of the vessel from the loss of 
central nervous influence. So whether the primary lesion is 
central or peripheral, the enduring change in the vessels is an 
unusual dilatation. The vessels, after a time, may become 
enlarged in all directions, and the want of room in which to 
accommodate increased length causes them to assume a some- 
what tortuous or spiral course. 

The alteration in calibre, whether diminishing or increasing, 
has the effect to greatly impede the circulation in the vessels. 
When the calibre is lessened the barrier is a mechanical one. 
for the density of the blood is much greater than that of water, 
and the effect is not that which would be secured in narrowing 
the channel of a river. When the diameter is increased the 
flow is retarded, first from the loss of contractility in the ves- 
sel, and second, as growing out of that, the admission of a much 
greater volume of blood into the part, with no unusual facili- 
ties for its exit. The result is that the blood accumulates in 
the part, the flow becomes more and more embarrassed, and 
finally more or less complete stagnation occurs, constituting 
what is known as " stasis/' or congestion. The increased ten- 
sion, interior to the focus of inflammation, and the effort to 
find relief through inadequate channels of exit, have the effect 
to crowd the smaller vessels, giving an appearance of an 
increase in the number. These are the pathognomonic changes 
in the blood vessels, and the alterations in the circulation con- 
sequent thereupon. These conditions alone will not account 
for the inflammation; up "to this point they are common feat- 
ures of extreme hvperremia. We must now extend our 
inquiry, and consider the changes in the blood itself. 

The first change in the blood is an increase of its rlbrinifer- 
ous character. As already said, it is not yet fully known 
whether this occurs before or after the establishment of the 
inflammation. It is certainly known that it occurs very early. 



PATHOLOGY OF INFLAMMATION 101 

It is true that the change in the blood vessels and the dimin- 
ished rapidity of the circulation would furnish the conditions 
for coagulation of librine. or even an increase in the haemato- 

blasts in the affected territory. When the inflammation is 
from an unusually energetic irritant, or from a prolonged 
operation thereof, the alteration in the vessels would readily 
account for the fibrinous character of the blood. But when 
inflammation on the other hand, occurs from what would be 
considered an irritant of feeble energy, or a brief exposure to 
its influence, it would seem that there must be some predispo- 
sition, probably in the state of the blood. When we reach etiol- 
ogy we will find that there are recognizable states of the blood 
that are truly causative. The presumption, therefore, is that 
in some cases the state of the blood predisposes to inflamma- 
tion, and in others the morbid action is responsible for the 
alteration in its character. The first class of cases may be 
held to be those in which the inflammation represents a veri- 
table morbid action, with a tendency to later and secondary 
forms; the latter an accidental condition with a tendency to 
resolution. 

It is not improbable that in some instances the albuminous 
and fibrinous elements of the blood may be in a relative excess 
from the loss of serum. We know that the slightest increase 
in vascular tension will give serous exudation, the albuminous 
elements not appearing in the exudate until the tension is very 
greatly increased. As a matter of fact in plethora, and some 
semi-pathological states, there may be a loss of serum materially 
raising the specific gravity of the blood. 

Xext to the increased coagulabilitv, the most noteworthy 
change in the blood is in the number of the leucocytes. In 
the commencement of the process there is no notable change in 
this respect, but very soon thev will appear in unusual num- 
bers. In watching the circulation in the mesentery of the cat, 
or web of a frog's foot, the red cells are seen to move along 
with such rapidity that the)' can scarcely be distinguished; the 
appearance is that of a continuous red stream. The white 
cells, however, are not carried along in the current of the 



102 ELEMENTS OF SURGICAL PATHOLOGY 

stream, but move slowly on the margins, even stopping now 
and then, and again moving on. Soon a number will accumu- 
late at some point, and commence to make their way, appar- 
ently, through the walls of the vessel. How is this exit made? 
Billroth (Surg. Path., p. 63) says: i; How do such num- 
bers of them get into the blood, and whence do they come? 
There are different views as to the mode of escape of wander- 
ing cells through the walls of the vessels. My views are as 
follows : The first change that we see in inflamed tissues 
during life, is dilatation of the vessels; the immediate results 
of this are increased transudation, and collection of white blood- 
cells along the periphery of the vessels. Then the wall of the 
vessel is gradually softened by some unexplained chemical 
process that goes on in every inflammation, so that by their 
active movements the white blood-cells gradually enter, and 
finally pass through it. Hence, dilatation of the vessels, 
accumulation of white cells along the walls of the vessels, and 
softening of the walls, seem to me to be the requirements for 
extensive emigration of cells. Cohnheim and Samuel have 

lately announced the same opinion According 

to Arnold, not only red but white blood-cells escape from the 
walls of the vessels at points where the capillary vessels leave 
small openings (Stigmata, stomata)." 

Undoubtedly these considerations have weight, yet there is 
something more than this. Some authors teach the escape is 
made by a fissure; others, that the vessel is torn, a process of 
traumatism. In opposition to all of this I must offer what can 
yet be called only a hypothesis. 

We know that when we have traced the capillaries to y their 
connection with, or continuation into, the venous radicals, we 
have not accounted for the passage of the blood plasma to the 
intercapillary tissue, other than by osmosis. We are further 
familiar with the fact, that for a long time certain tissues of 
the body were said to be non-vascular, because blood-vessels 
could not be traced into the tissue, but terminated on the pe- 
riphery in capillary loops. The typical tissues of this class were 
the cornea of the eye, and cartilage. How these tissues were 



PATHOLOGY OF INFLAMMATION IQ 3 

nourished became an important question to solve, and physiolo- 
gists and histologists bent all their energies to the task. 
They soon found that the blood-vessels were nourished by 
minute vaso-vasorum; that the Haversian systems of bone 
did not end in the lacunae, but canaliculi, which again subdi- 
vided into still smaller channels, many of them too minute for 
demonstration. The cornea was found to be composed of 
multitudes of cells, with "lymph spaces " between them, so that 
in acute keratitis the whole cornea was found injected, giving 
it a reticulated appearance, red at the periphery, where the 
spaces were larger, white near the center where they were 
smaller. In cartilage similar histological conditions were 
found. What is the natural interpretation? I offer the fol- 
lowing simply as presenting some elements of strong proba- 
bilitv, and as possibly opening up a new field for stud} 7 . 

May there not be a system of lymph spaces in all tissues of 
the body, soft as w r ell as hard, intermediate between the capil- 
laries and the venous radicals? Let us see. In moderate 
inflammation, many minute vessels appear that w r ere not visible 
before. Increase the intensity of the process, and the number 
is still farther increased, and so on until intra-vascular pressure 
is so extreme that the vessels give way, and the limit of injec- 
tion reached. No man will pretend to say that the greatest 
number of injected vessels just prior to extravasation fixes the 
limit of their number. No, because the fact of new vessels 
proves that in a state of normal vascular tension these vessels 
do not carry red blood. They are in anatomical communica- 
tion with the vessels that do carry red blood, and must have 
a physiological relation to them. The presumption almost 
amounts to a certainty that they carry the plasma. The red 
cells only convey oxygen, not taking any part in the forming 
of tissue apart frcm their stimulating function. The fact that 
the lymph fills the lymph spaces, and acts upon, and is itself 
acted upon by the blood, is well known; but the assumption I 
have offered, of a direct communication, by continuity, between 
at least some of the capillaries and these spaces, is the point at 
issue. The inflammation having subsided, when of a high 



104 



ELEMENTS OF SURGICAL PATHOLOGY 



grade (which is but another term for high tension), often 
leaves pigmentation of the parts. May it not be that the pig- 
mentation is caused by the imprisonment of red blood-cells in 
channels normally too small for them, when they return to 
their proper dimensions; imprisoned in channels in which they 
do not belong? My opinion is that when the leucocyte is 
supposed to be wandering i; free in the tissues," it is really 
moving in these lymph spaces, and is properly not out of the 
circulation at all. 

Stricker {Inter. Cyc. of Surg.) asserts, in the most positive 
and uncompromising manner, that the leucocyte does not 
escape from the vessel, and consequently never becomes a 
" wandering cell." He attempts to show that the fundamental 
phenomena of inflammation is a return of formed cells, or 
what he terms " basis tissue," to an embryonic state, and that 
the rapid transformation of this -basis tissue" gives the 
apperance.of amoeboid motion in a single cell. It may seem 
presumptuous to deny the accuracy of the observations of one 
like Stricker, yet it would be something akin to sycophancy 
to question the daily evidence of my own eye-sight upon no 
better warrant than unsupported statement, made by an active 
partizan, particularly when the mass of observers fully con- 
firm the conclusions of his adversaries. I give his statement, 
therefore, for what it is worth, but in a systematic treatise 
cannot criticise it as would be allowable under other circum- 
stances. At the same time I must express utter dissent, for 
two reasons: First, my own experience is opposed to it; and 
second, the experiments of Cohnheim, which have been amply 
corroborated by hundreds of observers, have the weight of 
argument, experience, and probability in its favor. Virchow, 
it is true, not writing in support of Cohnheim, indeed writing 
before him, refers to the metamorphosis of ' ; connective-tissue 
corpuscles" in inflamed parts, but does not attempt to fully 
describe the process. The doctrine of the escape of the 
leucocyte fitly supplements his teachings, and shows us how 
the disturbing force reaches the formed tissue. Hence the 
sum and substance of Stricker's teaching is, to carry us 



PATHOLOGY OF INFLAMMATION 105 

back twenty years in the development of pathology and wipe 
out all that has been learned in the interval. 

One or two points yet demand consideration. Can we 
demonstrate that the -stigmata," so-called, are openings of 
vessels? and how the larger white blood-cell pass through 
channels too small for the red cells? These questions have 
been partially answered elsewhere, but perhaps a further 
attempt may not be amiss. 

A study of small blood vessels will show that the branches 
are given off in such a manner that the openings are funnel- 
shaped, having the effect to make the inlet of the vessel much 
more capacious than the continuity of the tube. Now when 
the larger branches of the capillaries that carry red blood are 
under observation, there can be no misinterpretation of what 
we see; when the much smaller lymph canaliculi are reached, 
the funnel-shaped mouths may readily be mistaken for sto- 
mata. chiefly as the vessels leading therefrom are too minute 
to carry red blood, and consequently cannot be demonstrated. 
In a series of micro-photographs accompanying a report by 
Surg. J. J. Woodward, United States Arm}' [Histology of 
Minute Blood- Vessels), several of the photographs, notably 
plate No. 5, show these funnel-shaped openings very beauti- 
fully, although the observer conceives them to be stomata. 
Occasionally in studying a developing artificial inflammation 
one after another of these openings are seen to become filled 
with blood, their character being then unmistakable. Some 
do not assume this character, and the presumption is that the 
maximum of tension has been reached. Here again it is 
proper to state that Stricker (loc\ eit.) is found in opposition. 
He asserts that the appearance of an increased number of 
vessels is due to an actual manufacture of new ones. Thus 
the capillaries being protoplasmic, portions shoot out, and 
when processes from opposite sides meet, the solid cylinder 
becomes tubular by a process of vacuolation, and a new 
vessel is formed. This is true to some extent, but there is 
good reason for holding the theory that the stomatas are the 
mouths of small vessels. 



106 ELEMENTS OF SURGICAL PATHOLOGY . 

While on this point. I may add one more possible proof of 
the position taken. Take another diagram, found in almost 
any work on systematic surgery, that old picture of a rabbit's 
ear. with the vessels injected by inflammation. It will be at 
once observed that the '-new vessels" run out to a line point, 
and terminate in the tissues. Now we may enquire, which is 
the more probable, from our knowledge of the physiology of 
repair, that the permanent vessels do terminate in this man- 
ner? or that small vessels that do not normally carry red-blood* 
have become injected under the abnormal tension? 

Secondly, we are to enquire how the white cells find room 
where the red cells cannot enter. The walls of the lymph 
spaces, and the soft yielding character of the tissues, permit as 
great distension as the vessels, or rather compression. The 
reinforcing fibres at the openings of these minute vessels, will 
oppose a barrier to a red-cell, which the leucocyte overcomes 
by a change in its own shape. The red-cell can only get out 
of the ordinary current of the blood by pressure. When 
migration ceases, on the subsidence of the process, the white- 
cell is disposed of in various ways, at all events does not remain 
there as a prisoner. 

To return to our leucocyte in the vessel. We see it pro- 
trude its pseudo-pod, apparently into and through the w r all of 
the vessel, gradually i^s body passes into it; soon it is on the 
other side, the outside of the vessel, and is said to be i; free," in 
the tissues. This constitutes the distinctive feature of inflam- 
mation, viz., the wandering leucocyte, Let us be careful that 
we do not misinterpret it, however. The leucocytes are free 
in the case of adhesive hyperaemia. What is the difference? 
Very much, both as to method and purpose. 

As to method, it does not escape by any vital process, as in 
inflammation; it escapes with the other constituents of the 
blood in consequence of the wound. Furthermore, as to 
method, it does not go wandering in the tissues. It is not 
designed to stimulate permanent cells to renewed duplication, 
entirely, but is to duplicate itself and help make new tissue. 
It retains its ordinary spherical form; it shows few evidences 



PATHOLOGY OF INFLAMMATION 107 

of life; it soon becomes granular and organizes into tissue as 
in primary segmentation. 

Finally, the last change in the blood is when a state of 
arrest is reached, stasis, or what was formerly called "passive 
congestion." The extreme tension has now driven all the 
serum into the tissues; the outlets of the inflamed part cannot 
carry off the increased amount of blood; the white cells have 
to a considerable extent, escaped out of the vessels, and the 
red blood cells, are packed together, almost a dry mass dam- 
ming up the canal, and arresting the flow of blood. This 
furnishes us with all the conditions of heat, fever, swelling and 
other cardinal symptoms; the immense amount of oxygen 
taken to the part bv the red cells, the increased vascular ten- 
sion, the exudation, and modifications of tissue growth are all 
accounted for. Further changes are now destructive or retro- 
gressive. The flow must be reestablished, and the congestion 
relieved, as in resolution; the tissues must die, as in ulceration, 
when molecular, or in mass from starvation, as in gangrene; 
the imprisoned blood must break down, and disintegrate as 
in p} T asmia, septicaemia, or abscess; or the vessel become 
occluded, collateral circulation established; plastic formations, 
or some form of tumor result. These changes, and different 
forms of termination will receive attention in appropriate 
chapters. 

This concludes a brief resume of the facts of the pathology 
of inflammation, as far as they are comprehended to-day; if 
inefficient, as a complete treatise, the hope may be indulged 
that at least hints as to course of study have been given. 

As far as semeiology and diagnosis are concerned we have 
now found inflammation to consist in the establishment or 
succession of fourteen states, that may be arranged as follows: 

1. Modified Function, («) primary suppression, (/;) 

secondary hyper-secretion. 

2. Redness, or its equivalent, discoloration. 

3. Swelling, or its equivalent, exudation. 

4. Pain, or its equivalent, exalted sensibility. 

5. Heat in all cases. 



IOB ELEMENTS OF SURGICAL PATHOLOGY 

6. Primary arterial contraction. 

7. Secondary arterial dilatation. 
Increase of fibrine in the blood. 
Transudation of elements of the blood. 
Increase of leucocytes. 
Local stasis. 
Migration of leucocytes. 
Increased cellular activity. 
Fever. 



9 
10 

11 

12 

13 

J 4 



EXCITING CAUSES. 



As is almost invariably the case in morbid processes, 
the causes of inflammation are naturally divisible into two 
groups, the exciting and the -predisposing. In the present 
instance, however, notwithstanding the condition is eminently 
pathlogical, purely exciting causes have as important a place 
as the predisposing, owing to the possibility of severe and 
destructive inflammation occurring without the slightest pre- 
disposition thereto. These exciting causes may easily be 
summed up under four heads, and much difficulty will be 
experienced in sharply differentiating them from maintaining 
causes. Violence, morbid products, nervous alterations, and 
changes in the blood, are the commoner exciting causes. 

Violence may be considered as of two kinds, mechanical 
and chemical, and yet there is a certain similarity. Under 
the first head would be included all agencies which cut, bruise, 
or otherwise injure tissues, without introducing any chemical 
or toxical material. As a rule grave lesions do not induce 
inflammation, under ordinary circumstances; those which 
irritate rather than produce extensive tissue-change or solu- 
tion of continuity, are much more likely to be causative. The 
local irritation of a wound fulfills, it is true, the first indication 
for inflammation, viz., peripheral irritation and vascular con- 
traction; but the exudations in place of being into the tissues, 
as would be the case if there were no open wound, is on a 
free surface, and becomes reparative material. If the raw 
and sensitive surfaces are fretted or irritated by improper 



CAUSES OF [NPL.AMMATION 109 

dressings or want of care, inflammation may result. The rule 

holds good, that in the absence of some predisposition to 
alterations of the blood favorable to inflammation, it can scarely 
occur from the conditions ordinarily present in a clean uncom- 
plicated wound. Under circumstances in which exudation 
will be into the tissues, as a contusion, or a lacerated or 
punctured wound, the conditions of inflammation will be ful- 
filled, and such will be a common result. Even in such cases, 
however, as long as the individual is in good health, the 
chances are in favor of a resorption of the effusion, and a 
normal disposition of the devitalized tissue; traumatism induces 
inflammation when the result is productive of irritation; 
w r hen there are suitable changes in the blood; or when the 
devitalized tissues are not normally disposed of. 

The introduction ot chemical agents may produce inflamma- 
tion in many different ways. Thus the local effects may pro- 
duce irritation and changes in the blood vessels favorable to 
such a condition. They may be of a character to cause tissue- 
death (and, as will be sho-wn later, such foreign material may 
cause inflammation as a mechanical irritant), or by septic 
influence. Finally the poison may have a specific action on 
the blood. Thus an}- agent that would have the effect to 
increase the plasticity or "fibriniferousness " of the blood,, 
would be a potent one in establishing conditions most favorable 
to inflammation. 

Morbid Products, such as vesical stone, gallstones, gan- 
grene, and the like, frequently act as excitants to inflammation. 
The same may be said of coagulae of blood, and other normal 
elements of the bodv that are accidentally altered either in 
their relation to contiguous parts of the body as a whole, or in 
their physical characters or properties. Many of these prod- 
ucts are themselves the result of inflammation, and after the 
attack that has produced them has subsided, a period of 
quiescence may intervene, after which a renewal of the inflam- 
mation occurs in obedience to the principle that " a part once 
inflamed more easily becomes inflamed afterwards." Thus 
cystitis may, and frequently does produce a ropy-pus that 



HO ELEMENTS OF SURGICAL PATHOLOGY 

becomes the nucleus for stone. The stone once formed is 
causative of renewed inflammation of the bladder. The con- 
tinuous character of the inflammation, in these and analogous 
instances, would readily induce inflammation in parts not other- 
wise predisposed, and have the effect to very greatly increase its 
intensity and destructiveness. In some cases, again, an inter- 
esting question might be argued as to the secondary inflam- 
mation being a simple continuance of the primary one which 
induced the morbid action. Thus gangrene is one of the ter- 
minations of inflammation; the line of demarcation is not at 
the boundary of the inflammation. The inflammation in this 
instance is clearly not entirely due to the proximity of the 
dead tissue; it is largely a continuance of the primaiy inflam- 
mation. 

Innervation. — Disturbances of nerve action may cause 
inflammation, or favor its production, in one of two ways. 
We have already learned that central irritation will induce 
vascular dilatation and stasis from suspension of nerve stimu- 
lus. Wounds, therefore, in which nerve trunks are severed 
will be followed by inflammation in consequence of the injury 
inflicted on the nerves. There is still another method, and one 
too little insisted on by modern writers. The section of sen- 
sory nerves, by depriving parts of protection from foreign 
irritants, exposes such parts to inflammation entirely apart 
from any consideration of the effect of such lesions on the 
blood-vessels. This is often seen in paralysis with anesthesia. 
Thus in paralysis of the bladder, cystitis has been set up from 
the retention and subsequent disorganization of urine. Proc- 
titis has occurred in connection with paralysis of the rectum; 
conjunctivitis, with paralysis of the lids; inflammation of the 
lungs, when the pneumogastric has been divided, and many 
other instances. In case of paralysis, from idiopathic morbid 
action, such consequences are possible, and most observers can 
point to instances. In traumatic cases, however, such occur- 
rences must be rare, or at least of doubtful significance, as the 
injury to the nerves is of itself sufficient to produce inflamma- 
tion, without any reference to the entrance of foreign irritants. 



CAl'SKS OF INFLAMMATION m 

Even in cases non-traumatic, such influences must be ex- 
tremely slow in development, or almost innocuous, as sensory 
paralysis frequently secures abnormal tolerance of the part to 
irritation. 

Changes in the Blood, either from some actual or relative 
excess or deficiency in the elements, or the introduction of an 
irritant, is a very frequent, exciting cause for inflammation. 
In the first class of cases we find that i; poverty of the blood," 
a deficiency in the elements, furnishes a corresponding imper- 
fect repair. Death of tissue being in excess of repair, there 
will be imperfect defecation, of the body. It is equally 
true in the opposite state, viz., a relative or actual excess. 
Here there is more formative material than the body needs, or 
than can be carried off in the usual' way. The result is a 
retention of putrefiable material, peculiarly predisposing to 
inflammation on slight provocation. Acute anaemia, as from 
accidental haemorrhage; acute or traumatic ischaemia; similar 
states of plethora or hyperemia are one and all possible excit- 
ing causes of inflammation from the imperfect nutrition conse- 
quent thereupon. 

There may be, secondly, an accidental introduction of some 
specific irritant into the blood, such as venereal poison, snake 
venom, from rabies, as well as a chemical agent, as arsenic, 
Agents that would have the effect to cause an unusual plastic- 
ity of the blood, would in the nature of things furnish a very 
common condition essential to inflammation; there need be 
nothing specific in its nature, the mere increased coagulability 
would be amply sufficient. Other agents, specific or what 
might be called "chemical" in default of a better word — pro- 
duce the conditions of inflammation in various ways; some- 
times by retarding the current in the vessels, by vaso-motor 
disturbances; sometimes by some interference with the action 
of the heart; sometimes by a change in the blood from specific 
action in the elements, one or all; and possibly from a purely 
irritating property. In many instances the kind of poison 
introduced can be detected by the symptoms produced on 
organs or tissues for which it possesses affinity. Thus Arsenic 



H2 ELEMENTS OF SURGICAL PATHOLOGY 

will oftener affect the gastro-intestinal tract; Cantharis the 
urinary, and so on. 

This is a very brief outline of the exciting causes of inflam- 
mation, yet it may be found sufficiently comprehensive to 
include under one of the four heads nearly every imaginable 
excitant. Taken in connection with what has been said of 
diagnosis and pathology, there can be little difficulty in prop- 
erly classifying the multitudinous causes under the proper 
head. 

PREDISPOSING CAUSES. 

The predisposition to inflammation includes such conditions 
as render one person more liable than another. These are 
influences of a devitalizing character, peculiar habitual states 
of waste and repair; the retention of putreiiable excretions; and 
the previous occurrence of inflammation. 

Influences of Devitalizing Character play a very impor- 
tant part in inflammations, that are non-traumatic, from causes 
similar to alterations in the blood already noticed. Whenever 
the forces of life are lowered, it is evident that the demand 
for unusual repair, if met at all, must be in response to an 
unusual irritation; ordinary stimulus cannot do more than 
increase waste already too active. In such cases, if subjects of 
traumatism, there is often a failure in repair, and if it is 
attempted the process readily passes over into inflammation. 
Poverty, with its attendant innutrition, and unsanitary envi- 
ronment, furnishes the essential conditions in abundance. So 
also exposure to cold, extreme fatigue, or the exhaustion from 
long and serious illness. In all such cases waste is excessive, 
and repair taxed to the utmost to preserve even a very low 
standard of health; the slightest addition to the irritation or 
loss must inevitably result in inflammation. Paralysis, whether 
sensory or motor, is a case in point. In the one case we 
have the loss of protection from external irritants; in the 
other the dilatation of vessels from the loss of nerve stimulus, 
gives causes for predisposition to inflammation in abundance. 
A consideration of facts such as these, would warn the surgeon 



CAUSES OF INFLAMMATION 113 

against performing operations, unless emergent, when every 
care should be taken to improve the bodily condition of the 
patient in advance, if possible, or, if this is impossible, to meet 
danger promptly on its first appearance. 

Habitual Abormalities of Repair, such as syphilis, car- 
cinoma, struma, scorbutis, tuberculosis, and similar chronic 
morbid action, are frequently responsible for inflammation on 
slight provocation. Notwithstanding the majority of such 
morbid states are constructive in character, yet the tissue laid 
down is always of a low vitality, and the organism in general 
much weakened from the constant drain on its resources, to 
say nothing of the misappropriation of material furnished. 
These new tissues are of such low vitality, and imperfect 
organization, that little is needed to set up retrograde meta- 
morphosis, and disorganization. In all of them we have a 
state of continual overproduction, so much that there is a con- 
stant tendency to inflammation. 

Retention of Putreflable Substances, such as retention of 
urine in paralysis of the bladder, or fsecal matter in chronic 
constipation, frequently result in inflammation, first from the 
local irritation produced, and secondly from the absorption of 
some of the products of decomposition. The " defecation of 
the body" as Poland says ;i is nearly if not quite as impor- 
tant as its nutrition." When the enormous amount of excre- 
tion going on in a healthy body is considered, through the 
lungs, skin, urine, and intestinal tract, it becomes evident 
that the failure in any one of these emunctories must be very 
detrimental to the welfare of the organism, unless some com- 
pensation can be found. As one of the earliest predisponents 
to inflammation is alteration in the blood, either increasing its 
plasticity, diminishing its circulation, or impoverishing it in 
some way, the habitual failure^in excretion must sooner or 
later lead to such changes in the'blood in general, that, joined 
to the local irritation, will be exceedingly favorable to inflam- 
mation. 

Finally we should remember that a part once having been 
inflamed, readily takes on the same action again, and each 



ii 4 



ELEMENTS OP SURGICAL PATHOLOGY 



attack increases this facility. Why this is so is not readily 
explained; the fact is apparent. I have thought it might be 
done this way: A distinguished physiologist has said, that 
force in the organized body has a double purpose; to repel 
assaults of a disturbing character, and to maintain functional 
integrity under normal conditions. This force may be repre- 
sented as existing in definite proportions from the beginning 
of life in the individual, and when any of it is lost, through 
the exigencies of accident or disease, it is a permanent loss, 
and can never be repaired. It is a special deposit, that bears 
no interest, and may be drawn upon as long as any of the 
principal remains, and no longer. Every draft drawn upon 
this veritable corfs de 1'eserve, weakens future powers of 
resistance, and a ready explanation is found for the greater 
susceptibility of those who have once been ill to subsequent 
morbid impressions. 

It is evident that the distinction between exciting and pre- 
disposing causes cannot at all times be sharply drawn; the 
very conditions of the blood and innervation that predispose 
to such a morbid action are often and necessarily directly 
causative. There is one fact, however, that stands out very 
prominently, namely, that mere traumatism does not fill all 
the causative conditions; there must be an unexplainable 
change in the blood that converts a reparative and physiolog- 
ical hyperaemia, into an active inflammation. 

Prognosis considered with reference to continance of life, 
is dependent upon the extent and intensity of the inflammation, 
the tissues or part invaded, and the previous bodily condition 
of the individual. Thus a double pneumonia is more serious 
than a circumscribed lobular one; morbid action in the heart, 
is far more serious than a merely cuticular affection; should 
the individual be in poor health, particularly if suffering from 
some cachexia or dyscrasia, the effects of inflammatory action, 
both local and general, must be greater than when other con- 
ditions obtain. 

As to preservation of function, similar questions are to be 
considered. The intensity of the inflammation, equivalent to 



PROGNOSIS OF INFLAMMATION 115 

the degree of tension, determines the kind of exudate. Thus 
should the exudate be chiefly serous, resorption without 
enduring tissue-change must be the result. Should it be 
albuminous, or, in other words, should there be a large pro- 
portion of leucocytes, and the process active (acute), sup- 
puration is imminent, with some destruction of tissue as a 
consequence. Should the exudate be fibrinous, adhesion of 
contiguous parts is to be feared, sometimes lasting through 
life. Such adhesions may easily cripple the utility of parts, 
or cause pain from the inclusion of nerve filaments. In short, 
no matter what the question of immediate interest in prognosis 
may be, the answer will depend entirely upon the character 
of the tissues involved, the intensity of the inflammation, and 
the bodily state of the individual, modified or governed by 
the knowledge of the observer as far as the accuracy of the 
••foretelling" is concerned. In addition to what has been 
noted above, the surgeon will often be required to prophesy 
the Jbn?z of termination, in fact it will be essential for him to 
know, from the symptoms in a given case, whether the 
morbid action is to be succeeded by other forms. This can 
often be determined by the activity and rapidity of the process, 
the bodily state of the patient, the degree and duration of 
stasis, the character of the exudation, and the general environ- 
ment of the individual. The classical terminations, some of 
which will form the subject for special chapters — are as 
follows : 

Resolution, in which the effusion is resorbed, the circula- 
tion reestablished, and health restored with no notable or pro- 
nounced change succeeding, in either structure or function. 

Suppuration, in which pus is formed, either terminating 
the attack, or changing its character. 

Ulceration, in which the tissues suffer a granular death, 
and an open sore results. 

Gangrene, in which the affected parts die in mass, from 
arrested nutrition. 

Neoplastic Growths, from chronic, or sub-acute inflam- 
mation. 

I 2 



n6 ELEMENTS OF SURGICAL PATHOLOGY 

Besides these different forms or modes of termination, there 
are a number of complications, which have a certain relation 
to inflammation, and will need attention in separate chapters. 
They are, in order of importance, and possible frequency 
also — Erythema, a more or less evanescent cuticular inflamma- 
tion; Erysipelas, a contagious and virulent metamorphosis; 
Septicemia from the absorption of putrified organic material; 
and Pycemia a form of toxaemia characterized by multiple 
abscesses and typhoid conditions. 

Prognosis, however, has to do with still another question, 
relating to results depending particularly on the kind of tissue 
affected. When a tissue of somewhat loose texture is 
inflamed, resolution is generally perfect; occasionally, particu- 
larly when fibrinous exudation occurs, there is a resulting 
agglutination of fibres, and more or less permanent loss of 
function. The same result is often observed when tendons 
are implicated. Not only do we find tendons as a whole 
adherent to the sheath, but each fibre similarly attached; 
probably many deformities of joints, and so-called "contract- 
ures " are produced in this way. Many serous surfaces are 
thickened, or contract adhesions to near parts, as occurs in 
peritonitis, pleuritis, pericarditis, and so on. When the inflam- 
mation attacks glandular- structures, organs that are actively 
engaged in producticn or elimination, an enduring hypertro- 
phy, or hyperplasia is often the result; if this should involve a 
considerable portion, there may be a total loss to the organism, 
whether destructive or constructive depending upon circum- 
stances. Thus inflammation of a kidney may result in atrophy, 
or in hypertrophy with cystic degeneration; in the one case 
there will be such extreme tension and perfect stasis, that the 
nutrition is entirely destroyed, and urine ceases to be elimi- 
nated through the glomeruli, resulting in atrophic changes, 
should the inflammation last some time. In other cases, per- 
haps of less intensity, some tubules become obliterated, urine 
accumulates, and hydronephrosis, with cystic degeneration of 
the whole organ. In other cases pyonephrosis directly suc- 
ceeds the inflammation. In the spleen, liver and other glandu- 



THERAPEUTICS OF INFLAMMATION 117 

lar organs, the hyper-nutrition set up by the inflammation 

determines a hypertrophy that once established goes on 
indefinitely^ 

The vascularity of a part also determines the result. Thus 
in the cornea, cartilages, and similar structures, intense inflam- 
mation arrests nutrition, and necrotic processes ensue. If the 
parts are dense, and inelastic, as a bone, the imprisoned exuda- 
tion arrests nutrition by compression of vessels produced by 
the increased density. This gives us granular disintegration, 
as in caries^ or death and detachment of masses, as in necrosis. 
In cases of this character, while death of tissues or elements is 
going on in the one place, there is an ill regulated attempt at 
repair on the periphery, which has the effect to circumscribe 
the dead tissues, and also to imprison them by growing over, 
and thus the devitalized parts remain as a constant irritant, and 
establish a chronic inflammation, which may be considered a 
new form of morbid action. 

Therapeutics. — In the treatment of acute inflammation 
hygiene often claims prominent attention. Should the nutri- 
tion of the body be deficient, it should be improved; if oppo- 
site conditions obtain, it' should be diminished. In other words 
the surroundings of the patient should be of a character to 
favor recovery, as to temperature, light, dryness or moisture 
of the atmosphere, and the removal of any factors that may be 
directly causative. So also with the part; it should be in a 
position, elevated or dependent, as would tend to equalize the 
circulation, even, in some cases, to the extent of employing 
moderate elastic pressure and support. 

Adjuvants, in the way of topical applications, are often of 
value. Elastic pressure would fall under this head, and is of 
utility sometimes in promoting or hastening absorption. The 
most generally useful procedures, under this head, are hot »or 
cold applications. Heat is much to be preferred to cold, for 
obvious reasons: When heat is applied to a part the first, or 
primary effect, is to increase dilatation of the vessels: the reac- 
tionary effect, however, is to cause contraction, and this sec- 
ondary effect is far more durable. When cold is used, the 



Il8 ELEMENTS OF SURGICAL PATHOLOGY 

conditions are reversed; we have a primary contraction, and a 
secondary dilatation. Heat will have the effect to reduce the 
blood supply and thus inaugurate, in many cases, resolution. 
The better practice, in ordinary cases, is to dispense with all 
topical treatment, as it is often a practical repetition of the irri- 
tation; at times, nevertheless, it may be useful to resort to it. 

Remedies will at all times give the best results, more 
prompt in action, and more durable. There are few remedies 
in the Materia Medica that are without some relation to inflam- 
mation. Those more generally useful, types of a class, are 
perhaps as follows: 

' Aconite, when the case is acute, particularly in the earliest 
stage, that of suppression of excretion, the parts feeling hot, 
dry, and stiff. The patient is anxious, restless, and intolerant 
of heat. 

Apis mel. In inflammation of subcutaneous parts, the exu- 
date largely serous, oedema prominent, with pale, puffy swell- 
ing, and biting-stinging pains. Particularly indicated where 
the face is involved; fever, without thirst, and scanty or sup- 
pressed urine. 

Arsenic. There is also oedema, but more extensive, almost 
anasarcous, with dry, hot, burning skin, intense thirst, and 
great prostration with restlessness. 

Belladona. Intense inflammation, with hot, red, shining 
skin (radiating), and pungent heat, which seems to radiate 
from the part. Pains are severe and pulsative, worse from a 
light touch, but better from firm pressure. 

Cantharis. Cuticular inflammations, superficial, with vesic- 
ular surface; colorless exudation forming white crusts or 
scales. Pains are smarting and excoriating. 

Rhus tox. Also vesicular, but extending deeper, with 
rheumatoid pains, better from motion. The vesicles contain 
a yellow fluid, which dries up into yellow crusts, or leaves raw 
and sore excoriations. 

CHRONIC INFLAMMATION. 

Cases are occasionally presented to the surgeon in which 
long continued enlargement of glands, prolonged suppuration, 



CHRONIC INFLAMMATION IZ g 

or some condition which might represent a sequelae of inflam- 
mation exists, but which has no such history, the symptoms 
commencing insidiously, being unaccompanied by pain, and 
often with little if an}- disturbance of the general health. Not- 
withstanding there is an almost entire absence of the ordinary 
symptoms, prodromal and otherwise, of inflammation, yet the 
state is one of that character, modified by circumstances about 
which little is known. What has already been written about 
acute inflammation will be a proper introduction to a brief 
study of the differences characteristic of the chronic form, and 
following so closely it will be unnecessary to allude to more 
than the constant variations in causes, pathology, and results. 
It is possible to fill a volume with this subject, inasmuch, how- 
ever, as the process is very imperfectly understood, being to- 
day involved in obscurity equal to that relating to acute inflam- 
mation ten years past, a work that claims nothing higher than 
the position of an elementary treatise, can well afford to content 
itself with a simple narration of facts, leaving argument on 
their significance to more pretentious works, or until future 
study and experiment shall make clear what is now well-nigh 
incomprehensible. 

Whilst heat, redness, pain, swelling, and transient cellular 
activity are the constant and distinguishing features of acute 
inflammation, we find permanent structural changes of old, and 
a laving down of new tissues, the characteristic elements of 
the chronic form. Whether we study the genesis of tumors, 
of tubercle, of that protean disease scrofulosis, elephantiasis, 
and many other forms of morbid action, we find, in all alike, 
this peculiar form of inflammation lying at the beginning, and 
accompanying them in their development. Again, whilst most 
cases of chronic inflammation originate in an acute attack, very 
many commence in the chronic form, and without any of the 
ordinary symptoms of inflammation. The mere enumeration 
of these fundamental facts will serve to give an idea of the 
nature of the problems the surgical pathologist has presented 
to him; many of them, in the present state of the science, are 
utterly incapable of solution, even approximately. 



120 ELEMENTS OF SURGICAL PATHOLOGY 

As to anatomical and pathological characters, it may be 
stated that heat, redness, pain and swelling are frequently 
wanting entirely, or so greatly modified that, taken singly, 
there is scarcely a feature of inflammation present as given 
in earlier paragraphs. The vessels are enlarged, both in cal- 
ibre and in length; their coats are thicker, particularly the 
outer, or, when not so, very greatly altered in character; the 
tissues of the part are swollen, either in a state of hypertrophy, 
in which there is an actual increase in the size or density of 
the parts, or the cellular elements are excessive, as in hyper- 
plasia. The course of the process is slow, occupying, weeks, 
months or years, and the termination indefinite. At times 
there is a remittency in the symptoms with periods of indefi- 
nite duration, in which all local symptoms pass away. Famil- 
iar examples are seen in naso-pharyngeai catarrh, chronic 
gastritis, swelling of lymphatic glands, and many forms of 
ottorrhoea. A brief consideration of the ostensible causes may 
assist the student in comprehending the pathology,, and, per- 
haps, suggest a line of study, that may, if pursued, lead to an 
elucidation of the many vexed problems. 

Most writers are agreed that the exciting, and some say T 
the maintaining cause of chronic inflammation, is a continued 
local irritation. This has always seemed an utterly inadequate 
explanation, taken without any qualification. We know that 
in the case of a healthy- individual, a prolonged irritation will 
lead to active inflammation, terminating in a natural sequela?, 
more or less destructive in proportion to the kind, degree, 
and duration of the irritation. True, if the irritating medium 
cannot be disposed of, and suppuration or ulceration become 
profuse or extreme, the general health will suffer, the vital 
powers will flag, and the inflammation become chronic. This 
fact, gives a key to the true explanation, viz.. chronic inflamma- 
tion is due to prolonged irritation, -phis a disordered nutrition. 
Many such cases are met, commencing with some malnutri- 
tion due to occupation; as pelvic inflammatory 7 states, inaugur- 
ated by- hypermaeia from sedentary habits, or long-repressed 
stool, or excessive sexual irritation. We find at the bottom 



CHRONIC INFLAMMATION 12 i 

of such conditions, however, that there is what is popularly 
called a dyscrasia, or diathesis, either originating in the indi- 
vidual, or transmitted to him from his parents. These two 
words may be used indifferently, in the one case meaning 
*• disposition to," and in the other a '• bad habit." Rheumatism, 
arthritis, struma, tuberculosis, carcinoma, syphilis, and other 
conditions, are either transmitted to offspring by a survival of 
a peculiar disposition to the parent malady, and an unusual 
receptivity from deficient vital energy, or the diseased state 
may be transmitted in full operation. In either case, however, 
there is a manifest fault, plus or minus, in the formative 
sphere ; an abeiTation of energy which can only be recognized 
bv its manifestations, structural lesions being absent entirely, 
or existing only as effects of the morbid action. 

As with syphilis, and probably with all the dyscrasia, 
when matters of inheritance, the formative elements are first 
impressed, and soon, by transmission from cell to cell, the 
whole organism becomes infected, and local structural changes 
take place. In many cases of chronic inflammation, however, 
there is probably a simple defect in nutrition, some disorderly 
assimilation. 

There are some peculiarities in termination, some of which 
will receive attention later; the most notable are peculiar 
forms of suppuration. At one time calcareous concretions 
will form; at others amyloid or gelatinous deposits. Again 
the pus will become inspissated into a cheesy or lardaceous 
mass, or become liquefied and remain in cavities for a long 
time without undergoing further changes. 

The treatment must be eminently " constitutional," as it is 
called, and will require remedies of the so-called ; 'anti-psoric" 
group; remedies that have a long duration of action, as 
Anti C, Baryta C, Calc., Ferr., Lack., Lycofi., Merc, in all its 
forms, Phos., Sep., Si/., Sulph., Thuja, or Zinc, are particu- 
larly prominent. Beyond most of the fundamental conditions 
brought to the surgeon for treatment, none demand a more 
careful study of the -totality" than chronic inflammations; to 
give with any success an idea of the usefulness of any of these 



122 ELEMENTS OF SURGICAL PATHOLOGY 

remedies, would require a transfer of the entire pathogenesis,, 
and cannot, as a matter of course, be given here. When we 
reach special forms of the condition, such characteristic feat- 
ures as are of practical value will be given, but it would serve 
no good purpose here, and would only render frequent repeti- 
tion necessary. I may observe, however, that Anti C, Calc, 
Baryt. and Sulphur are oftener useful in the primary inflam- 
mation, without reference to the sequela?, than others, at least 
in my experience. 

Antimonium Crud: — When cuticular surfaces are involved, 
the parts are hard, shining and glazed; not specially painful, 
but often the seat of a fine pricking or stinging. Cold water 
often relieves. 

Calcarea Cai'b : — The parts are white, puffy and doughy; no 
pain, no tenderness, and local symptoms few and unimportant- 

Baryta Card: — Chiefly glandular irritations, progressing 
slowly, frequently repeated, with a tendency to the formation 
of calculi in the follicles. Chiefly of service in old people. 

Sulphur: — Somewhat similar to Anti C, but the skin is 
rougher; water is unpleasant, whether hot or cold, but par- 
ticularly the last. 



IX.— SUPPURATION 

Suppuration is the process resulting in the formation of 
pus, and may be considered both from a pathological and a 
physiological point of view. It is pathological when a product 
or sequel to inflammation, as it is eminently destructive. It is 
physiological when occurring as an element of repair, being 
conservative, and an essential factor in the process. It would 
be supposed, admitting the above to be a statement of fact, 
that there would be material points of difference in pus occur- 
ring under these circumstances, and such is the case. At this 
time it will be sufficient to state that in the one case the pus is 
what is known as "laudable," composed of two elements, the 
corpuscle and the liquor puris; in the other, the pathological 
form, there is an admixture of debris from the tissues, blood, 
and some notable modification in some of the proper elements. 
Whatever may be said of the connection of suppuration, of 
a pathological form, with the streptococus, the question does 
not enter into the discussion of the physiological form. 
Unquestionably bacteria are found in pus accompanying repair, 
but there is no evidence, satisfactory to me, that they are in any 
sense causative of the process, or even that they have any 
relationship to it whatever. There is much evidence at hand, 
on the contrary, that, even in pathological forms, the micro- 
organisms are, at least, not constantly causative, in fact they 
may be entirely without significance. 

Purulent Secretion. — Pus occurring on a free surface, in 
connection with repair, is known as a -purtdent secretion, and 
may be studied as the standard of pure or " laudable" pus. It 
is a semi-fluid substance, varying in specific gravity from 1.021 

123 



124 ELEMENTS OF SURGICAL PATHOLOGY 

to 1.040, of about the consistency of cream, yellow in color, 
inodorous, tastless, and unirritating. It is readily divisible 
into two elements, a fluid and a solid; the former is to all 
intents and purposes serum, and as such a simple vehicle; the 
latter is the pus corpuscle, presumably the leucocyte that has 
•outlived its usefulness. In other words, pure pus stands as the 
excess of reparative material. Nature always furnishes mate- 
rial of any kind in lavish abundance, far beyond the necessities 
of the case. Only a small number of the millions of seeds of 
plants floating in the air ever become fertilized, or becoming 
so, reach maturity. An insignificant number of mammalian ova 
ever become fecundated and mature. The same prodigality is 
observable in all nature's operations. In repair, as we have 
seen in an earlier chapter, all the injured tissues, the blood and 
the lymphatics furnish germinal elements to build up the new 
tissue. A comparatively small number are thus utilized; the 
greater number are superfluous, as far as building up the 
tissue is concerned, but not by any manner of means useless 
as to the process as a whole. The leucocytes, using the term 
in the widest sense, and including the white blood-cell as an 
emigrant, the same body in the blood current, and the lym- 
phoid cell, becomes the pus cell after death. That is, the true 
pus cell is a dead leucocyte, and one that has undergone fatty 
degeneration. Even as a dead body, the leucocyte has a 
function, namely to feed the growing cells. Indeed they have 
another function, also, to protect the forming tissue from out- 
side irritants. While living, there is little question, the pha- 
gocytic property of the leucocyte is active, and many a 
micro-organism is met and disposed of that might prejudice 
repair otherwise. The functions of pus, therefore, mav be 
summed up as protective and nutritive. It should be under- 
stood, however, that pus can only be looked upon as a true 
element of repair when occurring in open wounds, those that 
heal by granulation, or "second-intention." Occurring in 
wounds that have been approximated, and in accurate coapta- 
tion, it will probably have pathological significance. Even here, 
however, it may stand as a sort of exaggerated physiological 



PURULENT SECRETION 125 

effort, being often produced by an attempt at repair, too 
energetic for the occasion, and as to composition being undis- 
tinguishable from ••laudable" pus. In general, it may be con- 
cisely described as a process of luxuriation, and differs from 
inflammation and tumors in the following particulars: Inflam- 
mation is a state of overproduction, with an abortive attempt 
at organization. Tumors are a product of the same overpro- 
duction, with a more enduring organization. Suppuration is a 
still more energetic production, with no attempt, or the very 
feeblest, at organization. 

A microscopic study of " laudable" pus shows the cells in vari- 
ous stages; some living leucocytes, actively amoebic; others 
quiescent, but otherwise unchanged; others fatty, granular, 
and dead; others, now and then, broken up, and some of their 
particles, perhaps, seen in the interior of the proper tissue- 
forming cells. Of course none have probably seen a single 
cell go through all these various changes; but none can study 
a drop of pus, and fail to be convinced that each pus-cell 
started as a living leucocyte. 

The prognostic fact of value in this connection, is that the 
progress of repair can be determined by the quality of the pus. 
Thus when deficient, repair is feeble; when suppressed, repair 
is arrested, and some destructive morbid action threatens, as 
erysipelas, septicaemia, pyaemia, or the like. Should it become 
thin and ichorus, some destructive process is at work, ulcera- 
tion or gangrene; if offensive odor is developed, there is simi- 
lar probability. Should it become serous, repair is feeble. As 
long as it remains of normal character, all is going well; if it 
becomes changed, we give remedies to restore the normal 
character. 

Arsenicum, the pus is thin, brown, corroding, and bloody, 
with other evidences of disintegration. 

Belladonna, thick, yellow pus, not as fluid as normal, 
streaked with blood; high inflammation accompanying. 

Calcarea caj'b., pus thin, milky, curdled looking; or it is 
watery, without color, or odor, with small whitish lumps. 
Sometimes it is putrid-smelling, particularly when curdy. 



I2 6 ELEMENTS OF SURGICAL PATHOLOGY 

Calendula, when the pus is very profuse, but laudable. 

Graphites, pus thin, viscid, scanty, smelling like herring- 
brine. 

Hefar sulfh. Scanty, bloody, corroding, smelling like old 
cheese. This remedy has a powerful effect in promoting sup- 
puration. 

Iodine, enormous quantities of pus, laudable, but oftener too 
fluid. The excessive waste does not seem to have any ill 
effect on the patient. 

Lycof odium, very like the Calcarea pus, in general appear- 
ance, but is filled with " bubbles of air." 

Pulsatilla, copious pus, thick, bland, and of a greenish color; 
sometimes viscid. 

Silicea, brown, watery, slightly albuminous, gritty on rub- 
bing between the fingers; putrid odor. 

Sulphur, rather scanty, thin, putrid, of dark-brown, almost 
black color. 

ABSCESS. 

An abscess is a collection of pus in a cavity, whether 
natural or artificial, usually, if not always the result of inflam- 
mation. It is an eminently pathological process, and the pus 
presents characters that are very different from those of a 
purulent secretion. The fact that the pus is of such different 
characters goes for something in giving the process a different 
significance, but there are not wanting others, of even greater 
importance. It is true that suppuration of pathological type 
is typically expressed in the abscess, but it is sometimes found 
under other circumstances, on a free surface, or in connection 
with wounds. We have no term to express this condition; 
abscess is only partially applicable. While the facts would 
seem to warrant considering suppuration as of two varieties, 
physiological and pathological, yet there is far from being a 
general acceptance, one that would justify such a classification. 

The first question to command attention is, what is the 
cause for the difference in suppuration? Why should one 
variety be an element, and an essential one — in repair, and 



ABSCESS 127 

the other so eminently destructive. I admit that the majority 
of students and observers do not concede any such state of 
facts . The popular teaching is that all suppuration is path- 
ological and undesirable. Still I am of the opinion that the 
facts are as stated, and an answer to the questions propounded 
not hard to rind. 

We may divide all abscesses into two groups, the acute and 
the chronic: these again are divisible into two, the encysted 
and the diffused. The first classification has reference to 
course and natural history, the latter to conditions of develop- 
ment. 

Acute Encysted Abscess is the typical form, all others 
being modifications in one way or another. The natural 
history of this form is somewhat as follows: During the 
course of inflammation, or shortly after its subsidence, there 
will be a rigor, with some rise of temperature, pain or tender- 
ness on pressure over a small spot, followed by swelling, and 
in superficial regions, or those open to inspection, more or 
less redness. The swelling rapidly increases, as does also the 
pain, with corresponding intensity in color; later one point is 
seen to be more projecting, becomes decolorized, or changed 
in color, is softer, and soon gives way giving exit to the con- 
tents of the abscess, or pus. This pus is at once seen to be 
something different from the purulent secretion, being mixed 
with more or less blood, tissue-debris, and some variety of 
streptococus in the majority of instances. I say in the -major- 
ity of instances," for the reason that there are cases in which 
they are not found. Sometime after evacuation, varying from 
one to four or five days, the so-called ' ; core" is expelled, after 
which all symptoms subside, and repair goes on in an orderly 
manner if not interfered with. Now here is a pathological 
condition, as unmistakably so as the purulent secretion is 
physiological. Possibly a micro-organism may be causative, 
but I am not in possession of sufficient evidence to accept such 
teaching; as a matter of fact such evidence as I have goes to 
prove the contrary, and to show that such an agency is 
unneccessary, the whole process being perfectly explainable 



128 ELEMENTS OF SURGICAL PATHOLOGY 

without taking it into account. Let us see what the pro- 
cess is, and how the above symptoms may be explained. 

It has been stated in another place, that when inflammation 
ceases, the products disappear in due time. When, however, 
the attack has been of great intensity, with extensive tissue 
changes, and exudation of higher grade than serum, the prod- 
ucts are removed, if at all, only after a considerable interval, 
and quite imperfectly in many instances. If the products 
should undergo disintegration, and thus become more or less 
septic, either abscess or septicaemia will result according to 
controlling circumstances. That is, if the products are taken 
up by the absorbents, while in this decomposing condition, 
septic infection must occur. If they ar"e not thus taken up, 
they set up a renewal of the inflammation, which the state of 
the parts localizes, the tissues being agglutinated, and the 
secondary processes are, in a measure, shut off from neighbor- 
ing parts. 

At other times, it is possible, the migrating leucocvtes 
undergo reproductive changes in their new locality, and excite 
such a stimulation in the formed tissue that there is an immense 
production of living cells in a small space, which by their mere 
bulk, as a mass, induce consolidation of the tissues surrounding 
them, which later becomes inflamed and converted into a 
limiting wall. 

Again, cogulse will form, from extravasated blood, or 
-fibrinous concretions" result from changes in the exudate; or 
calcareous concretions from causes yet to be considered, and 
the irritation set up thereby will soon induce inflammation, 
isolated by the adventitious capsule thus formed, and a limit- 
ing membrane is constructed. 

No matter which of these conditions exists, the result is the 
same as to the formation of a limiting membrane or tissue, 
and one that is capable of active cellular proliferation, the 
proliferation being inwards, very largely, on the side of the 
cavity thus formed. This limiting membrane, or wall, has 
long been known as the " pyogenic " membrane, from the 
ancient conception that it was. the source of the pus. To 



ABSCESS 



129 



sonic extenl this is true, but it is far from being the solo source. 
The pyogenic membrane being once formed, the abscess has 
had a beginning, and now goes on to completion in a certain 
orderly manner. The organization of the pyogenic lining is 
weak and unstable, but outside of it a new one is constantly 
forming as long as the process continues. The most rapid 
growth of the abscess is towards the point of least resistance, 
which is ordinarily to the nearest surface, but fascia, or other 
dense tissues may determine a growth in another direction. 
As it approaches the surface the parts coyering it become 
thinned by pressure and distension, the blood vessels also 
obliterated, and soon "pointing" occurs. The complete devi- 
talization of the integumentary covering later results in its 
giving wav, and the abscess is evacuated. Soon after the 
pyogenic membrane becomes detached, it is thrown out as a 
••core,'' and the cavity left is rilled, as in' ordinary repair, 
normal suppuration continuing as a feature. Now the growth 
of the abscess is due to constant additions to its contents, these 
additions coming from various sources. There is a prolifera- 
tion from the pyogenic membrane; a possible segmentative 
augmentation of the leucocytes; an addition of serum from 
the increased vascular tension; the addition of particles 
from the disintegrating pyogenic membrane, which is con- 
stantly renewed by organization outside; some blood is prob- 
ably extravasated, and probably a deposit of salts from the 
serum. All this combines to render the elements of this 
pathological pus, as it may be called, something very different 
from that of a purulent secretion. 

It will be noticed that there is an area of induration, of vari- 
able extent, outside of the abscess. This is due to inflamma- 
tory exudation, which becomes organized into pyogenic mem- 
brane as the earlier constructions break down, the organization 
of the membrane in this successive manner having the effect 
to keep up the irritation essential for the maintenance of -the 
inflammation. When the abscess is discharged this irritation 
is rapidly lessened, and when the "core" is expelled, the 
induration speedily subsides, but does not entirely pass away 
until repair is completed. 



130 ELEMENTS OF SURGICAL PATHOLOGY 

This is the history of the typical encysted abscess, a popu- 
lar example being the common boil. But there are cases 
where no limiting membrane forms, and the abscess becomes 
as we say "diffused" What is the reason for this? The 
failure to organize a pyogenic lining is due to various modifi- 
cations of the ordinary process. The inflammation may be of 
great intensity, and rapid progress, as in erysipelas, for instance, 
and time for organization may not be permitted. On the 
other hand the process may be feeble, and material for organ- 
ization may not be furnished. In still other cases the inflam- 
mation may be of some specific character, or of a peculiarly 
destructive nature. When, from either of the above, a 
pyogenic membrane fails to be organized, the pus will follow 
in directions of least resistance, as in muscular inter-spaces, 
or in the loose subcutaneous connective-tissue, until it meets 
some barrier it cannot easily pass, when it will either find 
some new route, or "point" at the place where arrested. 

Chronic Abscess is a condition that bears the same relation 
to chronic inflammation, that the acute form does to acute 
inflammation. It is a result of chronic inflammation, oftener 
occurring in the glands, and in those of a scrofulous or tuber- 
cular diathesis. The semeiology is altogether different from 
the acute variety, and the composition and general characters 
of the contents very unlike. The process may occur in any 
part of the body, or in any structure, but is more frequentlv 
observed in the bones, and the glands of the neck. Perhaps 
the dorsal vertebrae are oftener affected than other bones. 
The prodromal symptoms are very obscure, and the com- 
mencement, as far as objectivity is concerned, very insidious. 
In some cases there is a long period of ill health, with anaemic 
symptoms predominant, and in others there will be no such 
history. Once established the symptoms are negative, until 
considerable swelling occurs, and even then there is little ob- 
servable beyond a slowlv increasing swelling, with no pain, or 
very little — no heat, no redness, and none of the symptoms 
usually associated with abscess. Whatever may have been 
the previous state of health, it is usually visibly impaired after 



CHRONIC ABSCESS 1 31 

the abscess becomes noticeable, although there are cases in 
which, from first to last, the patient is vigorous, and in ordi- 
nary condition. The course is very slow, often months elaps- 
ing before any signs of pointing are seen. The contents, 
when evacuation finally occurs, are of various characters, but 
never, or very rarely, resembling pus. Oftener it is watery, 
somewhat like skimmed-milk; sometimes "curdy," and occa- 
sionally colored, as green, bluish, dark-brown. In some 
instances it is albuminous, bland and unirritating; nearly always 
it is granular, giving a gritty feeling on rubbing between the 
finger and thumb; rarely is there anv odor, unless bones are 
affected, but when there is, it is cadaverous or putrid. The 
evacuation is not often followed by subsidence, the discharge 
usually continuing for a long time, and occasionally ulceration 
occurs, which is obstinate. The p}'ogenic lining is sometimes 
wanting, the limiting membrane being the cortex of the gland; 
in other cases it is very thick, but of low organization, looking 
not unlike paraffine, even being brittle. There are cases of 
diffusion, with no limiting membrane, as occurs in the so- 
called psoas abscess. 

The explanation of these phenomena is not difficult. When 
a gland is the seat of the abscess, the parenchyma is slowly 
destroyed, until nothing but the cortex is left. If an attempt 
at organization of a pyogenic lining is made, it will be very 
slowly accomplished, and few if any cells are derived from it. 
It grows by deposits from the contained mass, rather than 
proliferation; the fatty change in the cells being modified by 
the cholesterine in the old gland-tissue, giving the paraffine-like 
result. The serum exudation is slow, as the blood-pressure is 
not extreme, and the' chronicity of the process gives oppor- 
tunity for reabsorption, which favors a precipitation of the 
inorganic elements carried in it. When final pointing occurs, 
the relief from tension is not as marked, as in the case of the 
acute abscess, and there is no subsidence of the feeble inflam- 
matory action. 

Where the abscess occurs in bone, or tissue other than 
glandular, diffusion is the rule, and the chronicity of the pro- 

K 2 



I3 2 ELEMENTS OF SURGICAL PATHOLOGY 

cess, again, is not favorable to a limiting membrane. Ordina- 
rily the pus, if such it may be called — will burrow for long- 
distances before pointing, usually not until it reaches some 
fascia, or other obstruction, which it cannot pass. In this case 
the pus is filled with decomposed material, and when evacu- 
ated has a liighly offensive odor . 

Another condition, often resulting in abscess, must be 
noticed; glandular tuberculosis. In fact there are many who 
attribute all chronic abscesses to tuberculosis, and with good 
warrant. It is almost certainly the case when the process 
originates in the bones, and it is far from being unlikely that it 
is also the case in all other forms. A feature in the tubercular 
form of abscess, and one that is inexplicable if the "germ" 
doctrine as to tuberculosis is held, is the frequent absence of 
the baccilli either in the caseous glands before suppuration, 
or the pus in a later stage. The fact that the contents of such 
disorganized glands are tubercular is beyond question. If the 
common doctrine of pulmonary tuberculosis is true, certainly 
the micro-organisms should be abundant in the glandular 
form. 

In prolonged suppuration, whether acute or chronic, a con- 
dition known as " hectic," is developed. It is characterized by 
emaciation and prostration, night sweats and diarrhoea, pulse 
weak and rapid. The symptoms come on rapidly or slowly in 
proportion as the process is acute or chronic. Excluding the 
fact of suppuration there is nothing to distinguish it from tuber- 
culosis, which, by the way, many esteem it to be. 

Visceral Abscess. — Abscess of the viscera, or deeply situ- 
ated outside of the cavities, is often a matter very difficult to 
determine. The symptoms are obscure in the commencement 
of the process, and very often a diagnosis is not reached until 
the pus is expelled, and thrown out in some of the excreta. 
In many cases, a diagnosis is not reached during life, but such 
occurrences are less frequent than formerly, owing to the 
greater boldness of surgical practitioners, who no longer hesi- 
tate to open anv cavity of the body for purposes of explora- 
tion. There are certain symptoms that are, at least, suggestive 



DIAGNOSIS OF ABSCESS 



133 



of suppuration, and of sufficient urgency to warrant an 
exploratory operation. Among these the most common is a 
rigor, during the course of an evidently inflammatory action, 
followed by a sudden and considerable rise of temperature. 
Such symptoms are always suspicious, and when accompanied 
bv notable change in function, with a feeling of w r eight in the 
part, and sensitiveness to pressure, the presumption almost 
amounts to a certainty that suppuration has occurred. Owing 
to the loose texture of most of the viscera, the progress is 
usually very rapid, and the destruction extensive. The 
obscurity of the case is very great in the case of viscera that 
have no communication with the surface, as the liver, spleen, 
or brain. In the case of the lungs, kidneys or some of the 
pelvic viscera, pus soon appears, and the symptoms become 
explicable. The modifications of function that occur in other 
cases serve very well to locate the lesion, but inasmuch as the 
same symptoms would accompany any other, or rather many 
other morbid processes, the information furnished is small and 
may be very misleading. Possibly hectic is more pronounced 
in cases of visceral abscess than in the superficial form. 

Diagnosis. — Notwithstanding the apparently unmistakable 
character of the symptoms in most cases of abscess, it is 
not at all times an easy matter to make a diagnosis. Acute 
abscess may be mistaken for hernia or aneurysm, or vice versa, 
and the chronic form may well be mistaken for tumors both 
cystic and solid. Possibly the points of resemblance, and 
differences also — may be better presented in the form of a 
table 





Abscess. 


Aneurysm. 


Hernia. 


History. 


Inflammation. 


Traumatism. 


Traumatism. 


Form. 


Globular. 


Fusiform. 


Pyriform. 


Feel. 


Firm. 


Elastic. 


Elastic or 
Vermicular. 


Temperature. 


High. 


Elevated. 


Normal, or 
Elevated. 


Pulsation. 


None. 


Marked. 


None. 


Cough-impulse. 


Xone. 


None. 


Marked. 



J 34 



ELEMENTS OF SURGICAL PATHOLOGY 



Areola. 

Color. 

Pressure, 

Distal. 

Proximal, 
Lying Down. 
In general. 



Abscess. 



Aneurysm. 



Inflammatory. [Little, or None. 
Red, briorht. iDark red. 



Hernia. 



No Change. 
No Chancre. 
No Change. 
Fever. 



j Enlarges. 
[Diminishes. 
'No Change. 
!Local symptom 



None. 

Dark, or normal. 

No Change. 

Enlarges. 

Smaller. 

Intestinal 
Disturbance. 



It goes without saying that a question of diagnosis will 
only arise when the hernia or aneurysm is of recent formation. 
In the case of old aneurysm or hernia there can be no room 
for doubt if the abscess is acute. As to aneurysm, pulsation 
may be communicated to an abscess from a neighboring 
artery, and possibly there may be an adhesion to its sheath, 
or the abscess may be deep, beneath fascia. For these 
reasons alteration in pulsation by distal or proximal pressure 
on the artery, or even lifting the abscess up, in a direc- 
tion away from the artery, will give negative results in 
many cases. Stress is therefore laid upon the alterations in 
size on pressure, which can be appreciated by anyone. It is 
true that the pulsation in an aneurysmal tumor is unique, a 
sort of expansion, and a feeling as though a live animal were 
struggling beneath the hand. To detect this, however, 
requires more or less experience, and therefore cannot be 
relied upon for general use, while alterations in size can be 
appreciated by all, unskilled as well as skilled. 

Chronic Abscess may be mistaken for old hernia, or some 
form of tumor, oftener cystic. At times the diagnosis is very 
difficult, the condition being chronic, with none of the ordinary 
symptoms of inflammation. If the pus is very thin, the fluc- 
tuation will be .as marked as in cysts. The appearance of 
cachexia, when present, will suggest an abscess, but as this is 
not constant it is of little value. As a matter of fact it is of 
comparatively little moment whether a diagnosis is made out 



TREATMENT OF ABSCESS 



135 



or not, as the treatment will be practically the same in either 
case, :/:.. the extirpation of the giand or the tumor, whichever 
it may prove to be. Should a diagnosis seem necessary. 
however, resort must be had to the aspirator or exploring 
needle. This should be avoided, whenever possible, as dam- 
age may be done in various ways. A faecal fistula may be 
established, and the patient placed in danger of peritoneal 
inflammation; an aneurysm, with very thin walls, may rupture 
with fatal haemorrhage. For these reasons, if such explora- 
tion seems demanded, the surgeon should be prepared to go 
on with any operation that would be suggested. 

Treatment. — Naturally there are three indications to be 
fulfilled, depending upon the stage of development, very 
largely. The abscess may be aborted, or later must be opened 
and cure without recurrence secured. Abortive treatment 
must be institued before suppuration actually occurs, although 
I have seen cases in which the process was arrested after pus 
seemed to be formed. Merc. viv. is the typical remedy, 
although Hefiar s. may be called for in some cases. The 
remedy indicated by the existing symptoms is the proper one 
to use, as a matter of course, but one of the above is usually 
the simillimum. Nitric ac. is often indicated by the pricking 
pain, as if from a splinter, or piece of glass. 

Suppuration having proceeded so far that abortive measures 
are not indicated, the process must be hastened. Hepar s. is 
the usual remedy for this purpose, and has the effect to dimin- 
ish pain while greatly hastening development. The question 
that presses upon the surgeon for answer is : Shall the abscess 
be opened artificially, or allowed to do so spontaneously? 
Another question: Shall it be opened before pointing or not? 
A categorical answer cannot be given. The first considera- 
tion, usually, is where the abscess will be likely to point, and 
if the probable site is desirable or not. Should it, for any 
reason be undesirable, either from extra hazard, or possible 
disfigurement, pointing should not be waited for, but an open- 
ing made as soon as pus is unmistakably present. Such an 
event would be post-pharyngeal abscess, with a tendency to 



136 ELEMENTS OF SURGICAL PATHOLOGY 

work downwards; or one on the cheek which might open on 
the face; or in some accessible viscus when discharge into the 
peritoneum is imminent. There are other cases, as in felon, 
where the- abscess is underneath dense fascia, and pointing 
must be so greatly delayed that important structures may be 
damaged. In the case of felon, by the way, it is still a dis- 
puted question whether early incision, before pus has formed 
at all, may not abort the whole process. The testimony is 
somewhat conflicting, but I think there can be no question that 
the practice is a good one, as it, at all events, greatly shortens 
the attack. No matter what may be determined in the par-^ 
ticular instances referred to, it is the proper practice to open 
abscesses when pointing occurs, not permitting spontaneous 
discharge if it is possible to avoid it. The reasons are, first, 
that it shortens the process, thereby diminishing suffering, and 
limiting the destruction of tissue. Secondly, it gives much less 
scarring than when spontaneous discharge takes place. 

In opening an abscess, whether deep or superficial, precau- 
tion must be taken to avoid important structures, particularly 
blood-vessels and nerves, and to render the scar as small as 
possible by making the incision in some natural fold or crease 
in the skin, or, if there is no such mark, in a direction parallel 
to the fibres of underlving muscles. 

To fulfill the third indication, or cure without recurrence — 
the first thing is to hasten the expulsion of the "core," or 
pyogenic lining. This is accomplished, not by squeezing it 
(which may start up a new suppurative inflammation), but 
by giving Sulj)hur 30 x , one or two doses in twenty-four hours. 
It will be a rare occurrence if the core is not promptly 
expelled. In the absence of an}' special indication, Arnica is 
the remedy to cure the disposition to abscess, particularly boils. 

As to the use of poultices, with a view to hasten suppura- 
tion, the sole consideration seems to be to use some material 
that retains heat and moisture well. These two elements are 
all that are needed, and apart from this, one material is as 
good as another. 



X^ULCERATION 

An uicer is an open sore, differing from a mere lt abrasion" 

(which is a simple loss of epithelium), in the depth of the pro- 
cess; that is. it is a removal of proper vascular tissue. It 
may be due to morbid process of low intensity, operating after 
traumatism, or to something more energetic, as acute inflam- 
mation, or an organized deposit, as in syphilis. However 
produced it is a result of lost nutrition, the obliteration of 
small blood-vessels, and standing for an arrest of repair and 
exaggeration of waste. In the case of syphilis, or other con- 
structive process, the tissues are filled by a deposit, more or 
less organized, which devitalizes the parts by compression , 
cutting off their nutrition, resulting in a sort of molecular 
degeneration. At other times the new tissue displaces the 
old, and, owing to its low grade of organization, soon degen- 
erates, and is cast out, leaving an ulcer. To some extent this 
is the case with carcinoma, or malignant tumors in general, 
which are prone to break down. There is still another way 
in which the tissues may be destroyed, by processes not in the 
nature of morbid action. Among these traumatism, of various 
kinds — particularly burns — may remove so much tissue that 
the organism is unable to replace it; or the violence producing 
the lesion may be of a character to devitalize the surrounding 
tissues. In this category might be included prolonged pres- 
sure resulting in absorption. As to the production of the loss 
of tissue, it is a matter of minor moment how it is produced; 
the essential element is that there is a failure in repair. It 
may be inferred, from what has gone before, that this failure 
may be due to conditions general or local in character; also 

137 



138 ELEMENTS OF SURGICAL PATHOLOGY 

that it is not essential that the condition should be patholog- 
ical, as extent of surface may alone act as a maintaining con- 
dition, the emergenc\^ being far beyond the normal resources 
of the bod}\ 

The Exciting Causes may all be included under the single 
head of obstructed nutrition, from obliteration of small blood- 
vessels. 

The Predisposing Causes are of greater variety, and can 
be considered under various heads, such as sex, age, occupa- 
tion, habits, and surroundings or social condition. 

Sex commands attention from the clinical facts, and yet it 
is not easy to give it an exact value. Women certainly pre- 
sent more cases of ulcer than men, up to the age of fifty-five 
or sixty, when there would seem to be little difference in this 
respect. The lives of most women are notably more eventful 
than men. The monthly crises, peculiar to the sex, the occur- 
rence of pregnancy, the demands in lactation, possibly habits 
more or less sedentary, together with faults in dressing which 
derange the circulation, would seem to be sufficient to account 
for their comparative feebleness in repair, and resistance to 
morbid influences. Whatever the true explanation may be, 
the facts are that not only do women present more cases of 
ulceration than men, but there are certain varieties that seem 
to belong to them exclusively. 

Age seems to have, as would naturally be expected, a most 
powerful influence on the production and maintenance of 
ulceration, using the term more with reference to habits of 
body than years of life. Conditions of the body in which 
repair is imperfect, and waste excessive furnish all the essen- 
tials for ulceration, and we find it occurring with greater fre- 
quency among those past the middle period of life. The usual 
location is on the lower extremities, between the knee and 
the ankle, although they may occur in any region where 
exciting causes may be operative. I am not aware that one 
sex exhibits a greater predisposition than the other; men and 
women, in the decline of life, seem to be equally liable. 

Occupation as far as one exposes to traumatism more than 



ULCERATION 1 39 

others may have a relation to causation. The reception of 
injury under normal conditions, simply means an incentive to 
repair. A condition of mal-nutrition may exist, favorable to 
the production of an ulcer, however, and yet none result, from 
want of proper determining cause. Unquestionably, there- 
fore, other things being equal, those who are exposed to trau- 
matism from the nature of their occupation will be more likely 
to have ulceration than will others, in this respect, more hap- 
pilv situated. There is another influence of occupation, based 
upon the contact with chemical or medicinal substances that 
specifically cause ulceration. 

Habits, which include social condition and surroundings, 
may be considered one of the most potent factors in etiology. 
Habits of drink, debauchery, or use of opiates, as well as 
dwelling in damp, or badly ventilated quarters, together with 
insufficient food, furnish conditions in abundance peculiarly 
favorable to ulceration. Singularly enough the opposite end 
.of the social scale furnishes ample provocation. The idle and 
luxurious present examples of mal-nutrition quite as potent in 
this particular, somewhat different in kind, as in the case of 
the poor and overworked, or those of vicious lives. 

Common Characters: — All ulcers, ot whatever character, 
and regardless of dimensions, have certain characters in com- 
mon, and characters that have much to do with prognosis, 
diagnosis, and therapeutics. The earliest to appear, and that 
which is. perhaps, of greater value, for some purposes, is the 
Areola. This is a more or less circumscribed area of discolora- 
tion, after the appearance of the ulcer remaining as a zone 
surrounding it. It represents, prior to the actual lesion, the 
character of the process going on, inflammatory or necrotic, 
and later the progress of repair. Thus when inflammatory, 
the morbid process is still active; when simply hyperaemic, 
repair is progressing; when faint, repair is arrested or feeble; 
when dark, livid, angry, or oedematous, some destructive 
process is in operation. So also its texture, or rather its feel- 
ing furnishes important data. When soft and somewhat 
tumid, repair or extension is going on, depending upon the 



l_|0 ELEMENTS OF SURGICAL PATHOLOGY 

color; when hard and seemingly adherent to deeper parts, the 
process is either indolent and chronic, or extensive destruction 
is threatened again, depending somewhat upon color and other 
characters. 

Outline has reference to the general shape of the ulcer, as 
circular, oval, irregular, annular, semi-lunar, and the like. 
The state of the process, as to advance or repair, and some- 
thing of its pathological character may be indicated by these 
variations in outline. Thus, if the tissue be of equal resistance, 
a circular form indicates repair, if it appears a: a change from 
some other outline. It is the typical shape of the healing 
ulcer. An irregular outline usually indicates advancement. 
The annular or crescentic outline is often indicative of second- 
arv syphilis. 

Margin is the technical term for the edge, and its condition 
as to elevation or depression, sharp-cut or rounded, gives valu- 
able indications. Ordinarily elevation, not excessive, and 
somewhat rounded, signifies repair; elevated to a greater 
degree, and more rounded, indolence, or arrest of repair; 
sharp-cut. advancement, or rather continuance of the process; 
depressed, sometimes rapid destruction, when they are under- 
mined; or chronicitv. when adherent to deeper parts. 

The Sides are the more or less perpendicular slope from the 
edges to the base or floor of the excavation. When perpen- 
dicular the morbid action is still in operation; when undermin- 
ing the edges, there is active destruction: when sloping 
towards the center, depending upon the degree, either repair 
or chronicitv. 

The Floor or base of the ulcer presents many variations. 
Sometimes it will be covered by granulations, their condition as 
to color, size and firmness indicating repair or chronicitv. 
Again it is more or less flat, showing chronicitv; or ••worm- 
eaten," indicating continuing destruction: or covered with a 
slough, showing rapid advancement. Thus a disappearance of 
granulations shows a new or additional morbid action: the 
appearance of granulations on a hitherto smooth floor, indicates 
repair. 



TREATMENT OF ULCERS 141 

The separation of a slough may be the commencement of 
repair, when granulations will spring up — or another slough 
may form. 

Discharge varies greatly in character, and furnishes valu- 
able indications as to progress. The indications are the same 
as in suppuration in general, already referred to. As long as 
laudable characters are maintained, repair is going on; a sud- 
den disappearance means some septic infection; watery, weak 
repair; excoriating, destruction; gradual disappearance, failure 
of repair or cure; absence, chronicity, and indolence. 

Pain is a symptom of the least value, possibly, with the 
exception of useful indications for remedies. As is usual the 
tissue, and the susceptibility to pain will govern the degree 
and kind. Generally speaking, ulcers are not painful, at all 
events the pain is much less than the size of the lesion would 
seem to promise. 

Treatment in general, should be adjuvant as well as me- 
dicinal, and yet the essential element is the indicated remedy. 
I have cured very many ulcers with the remedy alone, not 
making any local applications, nor using any of the ordinary 
dressings, and even making no change in the patient's habits 
of life in the smallest degree. Nevertheless, whenever it can 
be done, the cure will be much hastened if other measures are 
added to the administration of the remedy. The general indi- 
cations to be fulfilled, as to adjuvants, is to equalize vascular 
tension, improve nutrition, and promote epithelial proliferation 
from the margins. It doubtless often occurs that one or the 
other of these must be ignored, and greater attention paid to 
the remaining features. Equalization of vascular tension may 
be secured by elastic bandage, of rubber or flannel — or adhe- 
sive strips; nutrition is sought in suitable food, and personal 
hygiene; epithelial proliferation may be secured by skin- 
grafting, or cell-grafting, sometimes reinforced by galvanism. 

In cases of unusual malignancy, or with some peculiar 
characters that would seem to threaten the vitality of the part, 
a question of amputation might arise; such an event, however, 
must be of rare occurrence. Plastic operations, of various 



142 ELEMENTS OF SURGICAL PATHOLOGY 

kinds, curetting and the like, have been employed now and 
then, but the results have never been of a character to warrant 
their retention among curative measures. 

The indications for remedies are more general than local, 
and do not need recapitulation in a work that does not profess 
to give more than ''hints." The many repertories and manu- 
als, to say nothing of the Materia Medica itself — are in every 
one's hands, and are reliable guides. Probably almost every 
remedy of which we have knowledge, has some relation to 
ulceration; it is manifestly impossible, therefore, to even give 
their names; it must suffice to mention, under each head, those 
that seem to be representative of a class. My own practice, 
it may be noted, is something as follows — as to the use of 
remedies: The general condition of the body as a whole is 
first considered, which will usually furnish indications for a 
number of remedies, the final choice (by '-exclusion'') being 
determined by the salient symptoms of the ulcer, chiefly pain, 
discharge, color of areola, and character of the granulations or 
the floor. The selected remed}' is then given, rarely in a 
low r er attenuation than the 30 x , at rather frequent intervals, 
say four times a day — until some change is apparent, no mat- 
ter how r slight, in any one of the local symptoms. Then the 
interval between the doses is increased, doubled, usually — until 
improvement is manifest, when all medication is suspended, as 
long as improvement continues. When it ceases, or begins to 
weaken, a few doses of the same remedy are given, in a 
higher potency, say the 200. to be discontinued when ad- 
vancement is again well established. During the whole time, 
all medicated, "stimulating," or irritating, applications are 
avoided, and nothing but water, without soap, allow 7 ed to come 
in contact with the ulcer. The water is caused to flow over 
the sore, with no violence, and not used more than once a 
day, unless the discharge is very abundant and of bad char- 
acter. Of course the dressings are changed as frequently as 
they become soiled. Many an ulcer well-disposed to close 
spontaneously, has been kept active by local measures, which, 
however well intended, have the effects to destroy new tissue 



CLASSIFICATION Ob 1 ULCERS 143 

as fast as it is laid down. When the discharge becomes laud- 
able, the surrounding parts are cleansed, as often as needed 
but the ulcer itself is undisturbed; it must not be irrigated or 
" cleansed," as the material removed is often just what is needed 
for repair and protection; the surplus will find its way out 
without aid. In chronic ulceration. I give at least three weeks 
to a remedy before giving it up; in acute cases as many days 
will be sufficient. 

Classification: — There is much diversity in the classification 
of ulcers, scarcely two authors agreeing. For some purposes, 
we might divide ulcers into atonic, tonic, and specific; in other 
words, those that have a tendency to cure, or remain station- 
arv: those that are progressive; or those that are characterized 
by the laving down of new tissue. For purposes of mere 
generalization, such a classification might serve a good pur- 
pose, but for therapeutic purposes it would be very inade- 
quate. I prefer to classify them with reference to causes, as 
far as the}' are understood, and find, I think, the following 
arrangement useful : 

Idiopathic, in which the conditions are purely local, and 
without reference to dyscrasia of any kind. 

Symptomatic, in which the ulcer stands as a symptom of 
some variety of morbid action, the location being purely a 
matter of accident. 

Specific, those which are associated with specific affections, 
being also an essential feature of the process. 

Such a classification, however, has defects, or rather is 
incomplete, as there are numberless varities of ulceration in 
any one class. For instance, a simple, idiopathic ulcer, is a 
type of the whole class, it is true, and yet it may, and often 
does, take on other characters that would seem to put it in some 
other category, if the original characters were lost sight of. 
Errors in treatment, purely adventitious occurrences, may con- 
vert a healing ulcer into a growing one, and yet the conditions 
are non-specific, and there is no disturbance of the general 
health, or, should there be, it will be due to the ulceration. 
While, therefore, there mav be many varieties under each 



I 44 ELEMENTS OF SURGICAL PATHOLOGY 

head, there are some that are so characteristic, and are met so 
constantly, that a sub-classification must be attempted. The 
following has proved quite satisfactory to me for practical 
purposes, in the past, and is offered at this time as having 
apparently justified itself. 

Idiopathic Ulcers, may be divided into simple, weak, indo- 
lent, and inflamed — which while differing from each other 
very materially, yet have this one feature in common, that the 
manifestations are purely local; they are not dependent upon 
morbid action general in character, nor indicative of any 
dyscrasia or diathesis. 

Simple Ulcers are the typical form, the tendency being to 
close spontanously. We find the areola is hypercemic, the 
outline oval or circular, the margins moderately elevated^ 
and rounded, sides sloping inwards, the floor covered with 
firm, florid granulations; discharge of laudable pus; -pain insig- 
nificant. The remedy particularly indicated, in the absence 
of any special symptoms, will usually be Calendula. 

Weak Uicers, are a development from the simple form, 
often due to the abuse of stimulating topical treatment. The 
primary effect of such treatment may often be to promote 
repair, but if too long continued the secondary effect is to 
retard, or even arrest it, and the following characters are taken 
on. The areola becomes faint, either a pinkish hue or light 
brown; in some cases fades away completely, but at all times 
is narrowed very much. The outline remains oval or cir- 
cular, as a rule. The margins are high, and somewhat 
everted, or depressed, depending upon the condition of the 
granulations; that is the more the granulations are developed, 
the greater the elevation and eversion. The sides slope 
inwards very much. The Jloor is either flat, and covered with 
a shining albuminous secretion, or else the cavity is filled with 
high, flabby, and pale-colored granulations, often seeming 
semi-transparent. The discharge is either arrested entirely, or 
is profuse, stringy and albuminous. Pain absent, or there 
may be a stinging and pricking, often only on contact. The 
remedies are usually found in the class represented by 



CLASSIFICATION OF ULCERS ja$ 

Alumina. Kali bicJi.. Atlti. crud. In sonic cases I have had 
good results from Sempervivum (the house leek) used 
locally, in fact making a sort of poultice of the fresh plant. 

Indolent Ulcers are eminently chronic, and often the result 
of energetic treatment of a simple sore, particularly when 
occurring on the lower extremities. I have never seen a weak 
ulcer on the lower extremity; nearly always they are on 
the trunk, particularly the shoulder. This has seemed to be 
so very uniform, that I am quite disposed to believe the weak 
and indolent forms are the same thing, the different characters 
being due to location, very largely. They are oftener met 
with in old people, who speak of them as " fever sores." The 
areola is dark, wide-spread, and irregular, the integument 
seeming to be bound down to the bone, and immovable; scaly, 
and rough in spots, and in others shining, as though varnished. 
The outline is very irregular; the margins flattened or de- 
pressed; the sides sloping inwards, or steep; thejloor is uneven, 
••worm-eaten ;*' no granulations; discharge either absolutely 
wanting, or a thin, brown, dirty and ill-smelling ichor; it is 
never profuse. There is not only no -pain, but in most cases 
the ulcer and surrounding parts are insensitive, and almost 
anaesthetic. The typical remedies are to be looked for in the 
so-called "anti-psoric " group, such as Sulph., Baryta card.. 
Sil.. Anti crud.. and the like. 

Inflamed Ulcers are also the result of energetic local treat- 
ment, as a rule, or of some traumatism inflicted on a simple 
one. The areola becomes inflammatory, bright red or dusk) 7 , 
sometimes swollen and oedematous; the outline is irregular, 
depending upon the tissue; in tissues of fairly uniform texture 
the process extends with equal rapidity in all directions, while 
in other cases, it will extend faster in one area, and slower in 
another, depending upon the resistance it encounters. The 
margins may be depressed or elevated, but the edges are 
usually sharp-cut; the sides are either vertical or undermined, 
the more rapid the growth the greater the undermining. The 
floor is uneven, granulations that have been formed disappear, 
and a slough of some character takes its place. The discharge 

L 



1 46 ELEMENTS OF SURGICAL PATHOLOGY 

is bloody, profuse, thick or thin, depending upon the activity 
of the process; the more rapid the process the thinner the 
discharge. Pain is usually considerable, and of almost any 
character. There is, also, more or less irritative fever, with 
some rise of temperature. Bellad., Puis., Merc* viv., Aeon., 
Rhus, may stand for the typical remedies. Most of the symp- 
tomatic ulcers commence as inflamed, oftener, probably, from 
causes not local in character; if an idiopathic ulcer becomes 
inflamed, the rule is that it returns to the simple type again, 
unless the treatment is injudicious. 

Symptomatic Ulcers, as already stated, are those that are 
dependant upon some dyscrasia, the locality being accidental, 
for the most part, the ulcer standing as a more or less essential 
indication of the morbid action. Even in this group, as a rule, 
the commencement of the process is in the simple form, but 
the typical characters soon appear. The varieties are as fol- 
lows: 

Sloughing' Ulcers have a dark or livid areola, more or less 
swollen and oedematous; the boundaries are usually quite 
sharply defined. Outline is ragged, the process extending in 
one direction more rapidly than another, depending upon the 
resistance of the tissues. Margins are depressed, as a rule, 
somewhat sharp-cut; the sides are undermined, and the floor 
covered with a slough, no granulations being present. Dis- 
charge is putrid and watery, more or less mixed with tissue 
detritus, and -pain is usually burning or gnawing, not particu- 
larly severe, but quite constant. There is always much gen- 
eral disturbance, fever, rigors, and sweat, but these symptoms 
vary in intensity, within very wide limits. The destruction of 
tissue is dependent upon the structure of the part invaded, 
and the activity of the process; in some cases extension is in 
depth, in others in superficial extent; in some rapid, and others 
slow, but at all times, such ulceration is serious, and the uncer- 
tainty as to what later phases may be, gives the observer con- 
cern. Arsen., Merc, viv., Lack., Nitric ac, represent the 
typical remedies, the essential feature rapidity in development, 
and wide destruction of tissue. 



CLASSIFICATION OF ULCERS 147 

Irritable Ulcers arc peculiar to women, and are usually 
associated with some menstrual abnormality. They are 
oftener on the lower extremity, over the crest of the tibia, and 
come on without assignable cause, at least as to traumatism. 
Those that I have seen give something like the following his- 
tory: For some days before the appearance of the ulcer, 
there is a peculiar, pricking pain, in a small spot, felt only 
when walking or standing, with no discoloration, at first. In 
a few davs. there will appear a dark, brown or purple spot 5 
about the size of a five-cent piece, rapidly extending in all 
directions, quite regularly circular in shape. Suddenly a min- 
ute opening, about the center, will occur, which rapidly 
extends, so that in the course of a da)' or two, an ulcer from a 
half an inch to an inch in diameter will form with the follow- 
ing characters; Areola dark purple, and flat; outline circular; 
margin sharp, and flat; sides steep; floor dark colored like the 
areola, and flat, no granulations; discharge not very profuse, 
either thin and watery, or thick and jelly-like, but always dark 
colored; fain most intense, and of varying characters, but 
oftenest burning. The remedies are typified in the character 
of the pain; Bcllad.. Cham.. Asa/., Merc, viv., and in the pro- 
dromal stage, Hydrastis. 

Hemorrhagic Ulcers are, in many particulars, practically 
identical with the irritable. They are the same in appearance, 
at times, and the symptoms are similar. The chief points of 
difference are: They are often multiple, and eminently 
chronic. They almost close between the menstrual periods, 
but become active again when the next period approaches, 
and discharge blood. Arsen., Carbo v., Phos., Silic. and 
Sulphur seem to be the typical remedies. 

Varicose Ulcers have no characteristic features; they 
may be of any type, and are worthy of separate consideration 
solely from their connection with varicose veins. This con- 
nection, however, has a therapeutic value, inasmuch as the 
varicose veins being cured, the ulcer frequently disappears. 
Nux. -corn.. Ham z\. Sulphur seem to be the remedies oftener 
useful. 

L 2 



I4 8 ELEMENTS OF SURGICAL PATHOLOGY 

Specific Ulcers, being a feature in specific disease, do not 
call for treatment at this place. As to the usual symptoms of 
the ulcer they may be of any type, and do not present any 
characters that, taken apart from the general dyscrasia, would 
have any significance, with one possible exception, to be dwelt 
upon in a later chapter. This is the character of the indura- 
tion. Most of the specific diseases are constructive, the 
characteristic feature being the laying down of new tissue. 
In the case of syphilis, the induration is at the base extending 
little if any beyond the margins. In cancerous ulcers, the 
induration is more in the edges, and extends out to the limits 
of the areola. In other particulars nearly all the ulcers accom- 
panying specific diseases, there are no distinctive characters. 

Remedies. It may serve a useful purpose to give the more 
particular indications for remedies, or at least such of them, as 
are oftener called for. Probably every remedy in the Mate- 
ria Medica will possess some symptoms relating to ulceration; 
those mentioned have been used in my practice, but it is very 
probable that the experience of others would add to the list 
somewhat. 

Acid mur. — Stinging, itching, and painful ulcers; foetid 
odor in the ulcer, although it is covered with a scurf; when 
touched there is a stinging pain ; putrid ulcers, with a burning 
pain or heat in the edges; jerking pains. Pus foetid and 
scantv. Worse in the afternoon and during the forepart of 
the night; also from cold, on lying down, on trying to lift any 
heavy weight, and in windy weather. Better from pressure, 
and on scratching. Left side chiefly. 

'Acid nit. — Drawing pain in the ulcers, which are very 
sensitive, and have an offensive odor; burning pain and heat 
in the edges; shooting and pricking pains; superficial ulcers; 
ulcers produced by Mercury. Pus foetid. Worse in the morn- 
ing, evening, and at night; also from bathing in cold water, 
on awakening from sleep, when lying on the affected side, 
and from being touched. Better in dry weather. Left side. 
(Since writing the notes from which this is copied, the follow- 
ing additional symptoms have been found, and proven reliable 



TREATMENT OF ULCERS i 49 

in one or two cases: Readily-bleeding deep ulcers; fistulous 
ulcers difficult to heal; pricking in the ulcers. Pus copious, 
bloody, corroding, or ichorous). 

Acid sulph. — Gangrenous ulcer; corrosive sensation in the 
ulcer; biting and cutting in the ulcer. Pus is corrosive. 
Worse in the forenoon and in the evening; also on getting up 
after lying down. ..Right side generally. 

Antimonium crud. — Fistulous, deep or flat ulcers; pain as 
if they were burnt; spongy ulcers with an itching or pricking; 
ulcers with high exuberant granulations; spongy ulcers with 
a sore pain in them. Pus scanty. Worse in the evening; 
also from bathing them, on getting heated near the fire, and 
on turning the part. Better in the open air. Left side. 

. \rgentum met. — Boring pain in the ulcer. Pus copious, 
gelatinous, bloody, or yellow, and sometimes corrosive. Worse 
in the forenoon, and in the afternoon; also when lying down 
in bed, and on descending an eminence. Better in the open 
air. on ascending an eminence, and on rising from the seat 
and moving about. Left side chiefly. 

Arnica man. — Jerking pain in the ulcer; bluish ulcers; 
readily-bleeding ulcers; indurated ulcers; induration of the 
surrounding skin; inflamed and itching ulcers; painless; prick- 
ing, pulsative, and sensitive ulcers; swollen ulcers with 
shocks, and feeling of tenseness. Pus bloody or gelatinous- 
Worse in the evening and at night; also from any bodily 
exertion, walking and moving, or turning the affected part. 
Better from warmth, when letting the limb hang down, from 
pressure, and w r hen lying down. Left side. 

Arsenicum alb. — Burning in the interior of the ulcer; pains 
are felt while sleeping; burning as if the ulcer were on fire; 
mortifying, putrid ulcers, with high edges, and shining red- 
ness of the surrounding skin; the base of the ulcer is either 
of a black-blue color, or has the appearance of lard; fcetid 
ichor, and proud flesh in the ulcer; thin scurf on the surface, 
it bleeds slightly on bandaging it; flat gangrenous, or inflamed 
ulcers, the surrounding skin is of a dusky-red, or rather of a 
purple color. Pus copious, bloody, ichorous or corrosive, 



150 ELEMENTS OF SURGICAL PATHOLOGY 

putrid, thin and watery. Worse at night; also before falling 
asleep, and again on awaking, from the cold, and in cold 
weather, any exertion of the body, lying on the painful side, 
on ascending an eminence, after moving about, from drinking 
liquors, and in windy weather. Better from warmth, on get- 
ting warm in bed, lying on the sound side, descending, and on 
rising from the bed. Either side. 

Asafcetida — Ulcers with intermittent, pinching pain. Exces- 
sively painful; pain relieved or changed to other kinds of pain 
on touching them. 

Aurum met. — Mercurial ulcers; itching, shooting, or burning 
pains; bluish-red, deep, fistulous, swollen and painful ulcers. 
Pus is yellow and foetid. Worse in the morning; also during 
rest. Better from motion, and while lying down in bed. 
Right side. (Low-spirited, sad, and constant thoughts of 
suicide.) 

Baryta earl?. — Gnawing pain; burning, or a pain as if burnt 
in the ulcer; corroding pains; scabby, crusty ulcers; indurated 
ulcers, difficult to heal; inflamed, itching ulcers; painless ulcers; 
pricking and pulsating; swollen ulcers, with a feeling of tense- 
ness. Pus scanty, or totally wanting; gelatinous and scanty. 
Worse in the night; also from cold, lying on the sore side, 
lifting the part affected, and from pressure. Better when 
lying on the sound side. Left side. 

Belladonna. — Desire to remain still; dread of motion; burn- 
ing in the ulcers on touching them; soreness and inflammation 
around the edges, with a black crust of blood in the centre; 
deep, scabby ulcers with cutting pains; fistulous indurated 
ulcers, with induration of the surrounding skin; painless, 
though inflamed ulcer, or those with pricking, redness, and 
inflammation of the skin for some distance around them; 
inflamed, sensitive and swollen ulcers. Pus scanty, bloody and 
ichorous. Worse at night; also on motion, however little, and 
from the slightest touch. Better while standing. Right side. 

Bryonia alba. — Ulcers with a smarting pain; stinging when 
moving; throbbing in the ulcers; induration of the edges. 
Pus brownish. Worse at night, after midnight, and in the 



TREATMENT OF ULCERS 151 

morning; also before falling asleep, from exertion of the body. 
on getting heated, when lying' on the sound side, on going up 
an eminence, from motion, or motion of the part, from making- 
pressure on the side of the limb opposite to the ulcer, on ris- 
ing from the seat or the bed, in summer and winter, when the 
weather changes, and during walking. Belter when descend- 
ing an eminence, lying on the sore side, from scratching, and 
while sitting still. Right side. 

Calcarea card. — Unwholesome, readily-ulcerated skin ; scrof- 
ulous ulcers; Fistulous ulcers, with redness, hardness, and 
swelling of the surrounding skin; carious ulcers; cutting pain; 
inflamed or putrid ulcers; high and feeble granulations, with- 
out much pain; painful soreness; tearing and throbbing in the 
ulcers; the ulcers are white or yellow. Pus scanty and albu- 
minous. Worse in the mornings; also just before falling- 
asleep, on awaking, when letting the limb hang down, 
before menstruation, from wet poultices, in the spring of the 
year, when turning the part, and in w 7 et weather. Better when 
keeping the limb elevated, in dry weather, and from rubbing 
or scratching. Right side. 

Calendula off. — Excessive secretion of pus; inflamed ulcers; 
painful as if beaten; surrounding parts are red; stinging in the 
ulcer during fever. Worse at night, with some fever. 

Cantharides. — Ulcers with itching and lacerating; burning- 
in the ulcers; smarting and stinging in the ulcer. Pus copious, 
inodorous, slightly yellow, and sometimes tinged with blood- 
Worse in the afternoon, and at night; also from drinking 
coffee, from rubbing and from scratching. Better when lying 
down. Right side. 

Carbo veg. — Pressure and tension around the ulcer in the 
leg; an ulcer which has become cured breaks out again, and 
instead of pus, emits a bloody lymph; the surrounding parts 
are hard to the touch; burning in the ulcer. Pus brownish. 
foetid, or foetid sanies; cadaverous-smelling and corroding- 
scanty secretion. Worse in the morning, and at night before 
midnight; also in the open air, evening air, before menstrua- 
tion, and from warmth. Either side. 



^52 



ELEMENTS OF SURGICAL PATHOLOGY 



Chelidonium. — Old, putrid, spreading ulcers; when lying in 
bed at night there is a chill with a warm body; deep, fistulous, 
spreading, itching ulcers. Worse in the morning; also in the 
open air, on turning the part, and when walking. Better from 
a firm pressure. Either side. 

China off. — Boring, w T ith painful sensitiveness in the ulcer; 
beating pain, only when moving the part; burning and press- 
ing, or digging; foetid, flat and gangrenous ulcers. Pus 
bloody, ichorous and foetid. Worse at night; also in the open 
air, from motion, from the slightest touch, and in windy 
weather. Left side chiefly. 

Cotiium mac. — Pains at night which rouse the patient from 
sleep; bleeding ulcers; the edge becomes black; gangrene of 
part of the ulcer; creeping, with a tensive pain; ulcers which 
are bluish, have a livid appearance and are tumid; pain in the 
part as if it were being beaten to pieces; burning, crusty and 
deep ulcers; painless, hard and fistulous; swollen ulcers, hard 
to heal; inflamed ulcers, with a feeling of tenseness. Pus 
foetid, watery and ichorous. Worse at night; also on descend- 
ing an eminence, on beginning to move, before menstruation, 
pain from rubbing or scratching, or when either sitting or 
standing a long time. Better on ascending an eminence, on 
letting the limb hang down, from motion, and from pressure. 
Right side. 

Graphites. — Unhealthy ulcers; proud flesh in the ulcer; 
tearing; crusty or scabby ulcers; hard itching ulcers, difficult 
to heal; sensitive, sore, spongy ulcers, that emit a salty flux. 
Pus bloody, watery, acrid and corroding; putrid pus, or 
smelling like herring-brine. Worse at night, before midnight; 
also during and after menstruation, and on moving. Better 
when lying down, and from pressure. Right side. 

Hepar sulph. — Mercurial ulcers; burning in the ulcers; 
burning in the night only; pains resembling recent excoria- 
tion; throbbing and shooting; ulcers with jagged edges, and 
surrounded by pustules; bluish, bleeding ulcers, with a burn- 
ing pain in them, and surrounded by blisters. Pus may be 
laudable, acrid, or sanguineous; smells like old cheese; or it 



T I v E ATM KNT OF \ r LCKKS 



153 



may be foetid and ichorous. Worse at night, and in the morn- 
ing: also on first waking up. from cold, when lying on the 
sore side, from pressure, on touching them; in clear, dry 
weather, and in a north or east* wind. Better when lying on 
the sound side, and in damp weather. Left side chief!)'. 

Kali bich. — Ulcers dry, form oval; have overhanging edges, 
a bright red inflamed areola, hard base; movable on the sub- 
jacent tissues; dark spot in the centre; after healing, the 
cicatrix remains depressed; the ulcers corrode and become 
deeper, but without spreading in the circumference; ulcers on 
the previously inflamed feet; ulcers on the ringers, with cari- 
ous affections of the bones. Worse in the morning; also from 
cold, and during the summer. Better from heat. Either 
side. (Lippe.) 

Lachesis. — The ulcer is large, and has a tendency to extend 
rapidly; surrounded by smaller ulcerations or pustules; con- 
siderable swelling, with a mottled, dark-blue or purple color 
of the surrounding skin; burning pain only when touching 
the sore; ulcers which are smooth, but have jagged edges, 
are surrounded by papillas, and are bluish or livid in appear- 
ance. Pus scanty. Worse in the evening, and at night 
before midnight; also in windy weather, in the open air, on 
changing the position, from pressure, while sitting, and in wet 
weather. Better when lying down, on rising from the seat, 
and in wet weather. Right side usually. 

Lyco-podhnn. — Fistulous ulcers, with hard, red, shining and 
inverted edges; inflammatory swelling of the affected part; 
itching in them only or chiefly at night; also when touching 
them; gnawing, shooting or tearing pain; tumid ulcers, with 
elevated and indurated edges; surrounded by papillae. Pus 
copious and albuminous; or sanious, gray, yellow, or acrid. 
Worse in the afternoon and in the evening; also while lying 
down on the sore side, before menstruation, on beginning to 
move, from pressure, while sitting, on being touched, and on 
beginning to walk. Better from cold, on motion, and on get- 
ting warm in bed. Right side chiefly. 

*In Germany, from whence we get this proving, an east wind is a dry one. 



i54 



ELEMENTS OF SURGICAL PATHOLOGY 



Merciirius sol. — Spreading ulcers; spongy, readily-bleeding 
ulcers; ulcers are exceedingly painful, and sensitive to the 
slightest touch; unequal elevations and depressions (neither 
hot nor cold applications allay the intolerable darling, lancinat- 
ing pain, G.); gnawing or throbbing pain; ulcers of a bluish 
or livid appearance, with hard, elevated and jagged edges; 
superficial ulcers, of a whitish appearance. Pus may be 
scanty or copious, and of almost any appearance (save laud- 
able, G.). Worse in the evening, and at night; also in the 
evening air, from or during walking or motion, from the 
slightest touch, on getting warm in bed, and in wet weather 
Better from cold (?), while lying down, and while sitting. 
Left side mostly. 

Mezereiim. — Pain of a burning character, of feeling as if 
from a recent excoriation; shooting pains; biting pains; prick- 
ing in the ulcer, or soreness; feeling of tenseness in the ulcer. 
Pus scanty or totally supressed. Worse in the evening, and 
in the night before midnight; also from rubbing, from scratch- 
ing, and from being touched. Better in the open air. Left side. 

JVatrum mur. — Superficial ulcers; red, angry-looking, 
smarting ulcers, surrounded by vesicles. No suppuration. 
Worse in the morning, and in the forenoon; also from bodily 
exertion, before and after menstruation, from motion, and on 
making pressure. Better while and after lying down. Right 
side. 

JVux vomica. — Raised ulcers with pale red edges; pain as 
if- being beaten to pieces; burning pain, as if burnt; jerking 
pain; prurient itching; sensitive sore ulcers, with a feeling of 
tenseness. Pus greenish and corroding. Worse in the morn- 
ing, and at night; also in the open air, after menstruation, 
while lying on the back, on moving the part, when touching 
the ulcer, when drinking liquor or coffee, when walking, in 
clear, dry, windy weather, and in Winter. Better when lying 
on the sound side, when sitting, and in damp weather. The 
right side chiefly. 

Petroleum. — Fistulous ulcers; rapid.y spreading; shooting 
pain, with elevated, indurated edges; deep or flat ulcers that 



TREATMENT OF ULCERS 155. 

are difficult to heal: pricking in the ulcer's edges, or areola; 
proud flesh in them; redness of the areola; painful sensitive 
and spongy ircers. Pus scanty, acrid and corroding'; sanious 
and watery. Worse in the morning; also in the open air, from 
cold in general, and in winter. Right side. 

Phosphorus. — Fistulous ulcers, wi'h callous edges; gnawing 
pain: hectic fever. Pus foetid and badly colored; scanty, and 
again is easily secreted. Worse in the evening, and at night, 
before midnight; also before falling asleep, on awakening, 
when the weather changes, and in the wind. Better on 
awakening. Right side generally. 

Pulsatilla. — Flat, putrid, carious ulcers; fistulous ulcers; 
itching, burning, or excoriated feeling in the ulcers; smarting 
and shooting pains; the surrounding parts are discolored; 
indurated and elevated edges; ulcers surrounded by papilla?. 
Pus copious, albuminous and yellow; also bloody or green. 
Worse in the evening, in the afternoon, and at night before 
midnight; also on changing the position, while lying on the 
sound side, after lying down, during menstruation, on begin- 
ning to move; also after moving, on pressure on the side of 
the limb opposite to the ulcer, on rubbing or scratching, while 
sitting, and in windy or wintry weather. Better in the open 
air. from cold in general, motion, on walking, and on wetting 
the affected part. Right side. 

Rhus tox. — Small vesicles, turning to putrid, gangrenous 
and spreading ulcers; violent fever; tingling and smarting as 
if from salt in the ulcers; burning, creeping or crawling sensa- 
tion, with a pain resembling a recent excoriation; smarting 
and soreness; ulcers surrounded by papillae. Pus sanious and 
acrid. Worse in the morning, evening, and at night after 
midnight; also before falling asleep, in the autumn and spring, 
from bathing in cold water; also from exertion of the body, 
when lying down, from poultices, when the weather changes, 
and in wet weather. Better from motion, and motion of the 
affected part, while walking, and in dry weather. Either side 
may be affected; chiefly, however, the left. 

Secale cor. — Bleeding ulcers; ulcers becoming black, feel- 



156 ELEMENTS OF SCTRGICAL PATHOLOGY 

ing as if burnt; painless ulcers; pricking, producing a pruri- 
ent sensation. Pus putrid. Worse at night, also from being 
touched, and on getting warm in bed. Better from cold. 
Right side. 

Sempervivum tect. — Immense jelly-like granulations; -pus 
thin, scanty, colorless. 

Sepia. — Ulcers with blisters around them; pain as if burnt; 
deep, crusty (scabby) ulcers; flat ulcers with digging pain; 
destitute of feeling; fistulous, hard ulcers; high elevated 
edges; hard to heal; jerking, itching or pricking; proud flesh 
in them; pustules around the ulcer, with redness of the areola; 
sensitive, sore, spongy or swollen ulcers; swelling of the 
edges, with tearing in the ulcer. Pus is copious, corroding, 
gelatinous, greenish or ichorous; or it may be scanty, putrid, 
viscid, sour-smelling, and whitish or yellow; thin, salty ichor. 
Worse in the morning, forenoon and evening; also before 
falling asleep, and on awaking, while sitting, and from being 
touched. Better on awaking, and when rising from the seat. 
Right side. 

Silicea. — Aching pain in the ulcer; it becomes black at the 
base, or on the edges; bleeding from the base or edges; bor- 
ing or burning in the edges, or in the areola; sensation of 
coldness in the ulcer; deep or flat, crusty ulcers; destitute of 
feeling; hard, fistulous or gangrenous ulcers; ulcers with 
high, hard edges; difficult to heal; jerking and itching in or 
round about the ulcers; pricking in the edges and areola;, 
proud flesh in the ulcer; pulsating, putrid ulcers, with redness 
of the areola; sensitive edges; spongy ulcers, or only spongy 
on the edges; swollen ulcers with white Spots and tearing 
pain. Pus copious, brownish, corroding gelatinous, or grayish, 
bloody, or ichorous; scanty, putrid, thin, and watery and yel- 
low. Worse in the forenoon, afternoon, in the evening, and 
at night; also in the open air, when lying on the painful side, 
from pressure, and when the weather changes. Better when 
lying on the sound side. Either side. 

Sulphur. — Readily-bleeding ulcers; ulcers with raised and 
swollen edges; surrounded by pimples; fistulous ulcers; sting- 



TREATMENT ^\' ULCERS 157 

ing and lacerating in the ulcers; proud flesh in them; violent 
bleeding of old ulcers; irregular jagged edges; oedematous 
swelling, and reddish-brown discoloration of the skin. Pus 
thick, yellow, and foetid; or thin and foetid. Worse in the 
evening, and at night; also on awaking, from bodily exertion, 
while lying down in bed, before menstruation, from poultices, 
from being touched, and on getting warm in bed. Better 
from cold, on rubbing or scratching, and in dry weather. 
Left side. 

Thuja. — Ulcer with indurated edges; elevated jagged edges ; : 
surrounded by blisters containing pus; deep, burning and 
fistulous ulcers; itching, pricking, and proud flesh in the 
ulcers; pulsating, spongv ulcers, or only spongy on the edges; 
feeling of tenseness in the ulcers; ulcers with serrated edges. 
Pus vellow. Worse in the afternoon; also on rising from the 
bed. Better from rubbing or scratching. Either side. 

Tartar cmet. — Deeply-penetrating, malignant ulcers; broad 
and deep sloughing ulcers; gangrenous, with hectic fever; 
ulcers surrounded by black pustules, which break down into 
deep ulcers. Pus absent; merely an oozing of foetid humor. 
Worse in the morning. Either side. 

Zincummet. — Herpetic ulcers; bleeding and burning ulcers; 
destitute of feeling; itching, redness of the surrounding skin; 
sore ulcers; tearing, and feeling of tenseness of the ulcer, and 
the surrounding parts. Pus bloody and corroding. Worse 
in the afternoon and evening; also on getting heated near the 
fire. Better from rubbing or scratching. Left side. 



XL— MORTIFICATION 

Mortification is a generic term, meaning death of tissues. 
More specifically we speak of death of soft tissues as gangrene, 
and of hard tissues as necrosis. These terms refer to the pro- 
cess; the dead tissue is a slough, when in soft parts, and a 
sequestrum when in hard tissues. The process of separation 
of the slough, is known as sloughing, and of the sequestrum, as. 
exfoliation. 

The essential cause for mortification is vascular obstruc- 
tion; anything which cuts off the blood supply, suddenly, 
without affording time or opportunity for the establishment of 
•collateral circulation, will be followed by death of the part. 
There is no question that there are micro-organisms that have 
a close relationship to putrefactive processes. There seems to 
be equally no question, at least in the minds of very many 
competent observers — that living tissue, of normal vitality, is 
unaffected, in any appreciable degree, by bacterial contact. 
As far as we are able to judge, from the study of pathological 
processes, mortification never occurs without vascular obstruc- 
tion, The causes for this are various. In the majority of 
cases, probably, embolism occurs, either from traumatic causes, 
or some alteration in the blood; in another considerable num- 
ber violence done the blood-vessels as division, or compression 
is causative. There are other cases, to be noted more at 
length later, in which changes in the blood-vessels occur from 
various causes, that determine changes in the blood (or these 
changes are due to the same general causes) that gradually 
obliterates systems of vessels, in such a way that extensive ter- 
ritories are deprived of blood. In still other cases, and it is 

15S 



A.CUTE GANGRENE 



r 59 



this class that puts the subject in the present category — inflam- 
mation may result in embolism, and thus mortification may be 
considered one of the terminations of inflammation. Whether 
an inflammation of high grade, that is great intensity — ter- 
minates in ulceration or mortification, depends upon the mag- 
nitude or number of the vessels obliterated; the vessels being 
small, capillaries or arterioles, ulceration results, a molecular or 
granular disintegration. If large vessels are closed up, the 
tissues die in mass, or as we say. mortification ensues. 

One characteristic of mortification is somewhat different 
from other forms of morbid action. There is no retrogres- 
sion. The parts once dying are dead beyond hope of revivifi- 
cation; they are forever lost to the economy. They are cast 
off. as worn-out dead matter, and the place from which they 
came is filled up by new material, not in any sense a conver- 
sion of the dead tissue. This fact is worthy of mention, inas- 
much as it determines the therapeutics. The object of treat- 
ment is obviously to limit the extension of the process, hasten 
the separation of the dead tissue, and promote repair, There 
are many varieties of gangrene, based upon differences in 
semeiology, but from a pathological point of view they may all 
be included under two heads, the acute and the chronic. 

Acute Gangrene, otherwise called "hot," or " moist," is 
usually of traumatic origin, but occasionally appears as a result 
of intense acute inflammation. The essential conditions are 
that the circulation should be suddenly cut off, the vessels 
themselves being in a normal condition at the time. Division 
or compression of blood-vessels, or embolism are the causative 
factors. The occurrence of embolism would argue something 
pathological as to the blood; other usual causes are entirely 
without pathological character. 

The symptoms of acute gangrene come on in a certain 
order, the earliest being determined somewhat by the immedi- 
ate cause. When embolism occurs, there is often a sharp 
pain, quite acute for the moment, at the point of lodgment. 
Sometimes this will continue for a long time, and again it will 
be of only momentary duration. There are cases in which it 



•l6o ELEMENTS OP SURGICAL PATHOLOGY 

is continuous during the process, only ceasing when sloughing 
has been accomplished, and repair well advanced. In trau- 
matic cases there is usually little if any pain, the first symp- 
tom being a loss of pulsation in the artery beyond the point of 
injury, and rapid fall of temperature. Later the temperature 
will rise again, sometimes quite to the normal, or even a little 
above, probably due to the disorganizing process going on. 
There is usually early swelling of the part, and very shortly a 
change in color in the most distant parts, such as the tips of 
the fingers or toes, or the heel. The change in color is oftener 
a decoloration, at first, then becoming livid, and later a bluish 
black, shading off into the color of the part. The discolora- 
tion extends slowly or rapidly, depending upon the size of the 
vessel involved, and somewhat upon the state of the tissues, 
but increasing in rapidity as time goes on; that is decomposi- 
tion once established, it goes on with increasing rapidity. 
When the point of obstruction is reached, further progress is 
arrested, and a new process commences, elimination and 
repair. This line, the line of demarcation, is usually sharply- 
defined, a zone of inflammation, or high grade hyperasmia 
separating the dead tissues from the living. There is usually 
little pain, until the line of demarcation is formed, but it then 
sometimes becomes quite considerable. There is more or less 
irritative fever, becoming somewhat more pronounced when 
the line of demarcation is formed — in cases when the amount 
of tissue involved is considerable, becoming of high grade with 
mental disturbance, sometimes delirium, and again a mere 
apathy or confusion of the mind. Quite often there will be 
septic or pyaemic conditions develop, usually, however, late in 
the process. As the process of sloughing goes on, if per- 
mitted to do so, the general disturbance increases in gravity. 
The dead tissues, at the oldest points, by the time the line of 
demarcation has formed, are greenish black, the skin peeling 
off in strips or patches; a putrid-smelling discharge, thin and 
watery ; the later parts bluish black, swollen, and crepitating on 
pressure, from the gases of decomposition. The tissues 
undergo decomposition in a certain order: First the skin, then 



PROGNOSIS OF GANGRENE j6i 

the muscles; later the blood vessels, still later the nerves, and 
last of all the ligaments and denser connective-tissue. The 
odor accompanying this sloughing process is very offensive, 
and being caused by loading the air with the products of 
decomposition might be considered an active agent in the pro- 
duction of the constitutional disturbance. When sloughing is 
complete, the dead parts fall away from the living, leaving a 
granulating surface. It is needless to say, that in acute gan- 
grene, the surgeon would not permit this process to go on in 
the typical way. The moment the point of obstruction in the 
artery could be determined, some surgical procedure would 
be instituted. This will be considered, however, later. 

Prognosis depends first, of course, on the magnitude of 
the vessel involved, or the number. Arrest of circulation 
high up in the femoral for instance, would be a much more 
serious accident, than in the popliteal, both from the size of 
the vessel, and the number of secondary branches involved. 
Damage to the popliteal, as a case in point, would cut off the 
circulation of the leg entirely; while if lower down, one of 
the tibial supply would be lost, and a portion, at least, of the 
leg be saved. Prognosis, therefore, as to extent of tissue 
imperilled, would be dependent upon the size and number of 
the vessels destroyed, and the same fact would determine the 
danger to life. The constitutional symptoms are dependent 
upon the amount of tissue involved, as more vital effort is 
required to eliminate a large amount than a small one, and 
the demands upon the reparative forces are greater. The 
bodily condition of the patient, the facility with which repair 
is ordinarily secured, the state of health of the individual, 
must all enter into the solution of the problem. Questions of 
amputation are also to be considered, as in cases where the 
whole of an extremity is involved, amputation would be a 
necessity, either before or after the line of demarcation was 
established; while in gangrene of less extent, it would prob- 
ably be outside of the case altogether. The nature of the 
parts involved would have a controlling influence on prognosis. 
Necessarily visceral gangrene, notably of the lung, or intes- 

M 



162 ELEMENTS OF SURGICAL PATHOLOGY 

tinal tract, would be a much greater calamity than of one of the 
extremities. The occurrence of pyaemia, or septic infection 
would greatly complicate the case, as a matter of course, but 
not necessarily be fatal. 

Diagnosis. — It is possible that haematoma, or ecchymosis 
might be mistaken for gangrene, in the living subject, and 
hypostasis, or suggillations in the dead, might be mislead- 
ing in causing a false estimate of the cause of death. The 
history, when obtainable, would necessarily be an important 
item, but as the same injury that produces extensive ecchy- 
mosis might also result in gangrene, something more is 
occasionally required. The fact that the temperature is low- 
ered, crepitation on pressure, no staining of the surrounding 
tissues, as would occur when there is extravasation, and the 
cadaverous odor should distinguish it from ecchymosis, during 
life. Post mortem indications are easily obtainable, and posi- 
tive. The areola, on the forming line of demarcation, might, 
perhaps, be mistaken for staining, in exceptional cases, but as 
a rule it is inflammatory, and quite different. 

Treatment depends upon the cause, and extent more than 
any other elements. In traumatic cases, that is when the 
artery is divided, if collateral circulation is not established, 
gangrene of course is inevitable, and treatment must be 
directed to getting rid of the dead tissue as speedily as pos- 
sible. If the whole circumference of a part is involved, and 
the process extends through the entire structure, amputation 
would be indicated as soon as the point of division can be 
determined, provided other things are equal. If there should 
be much shock, consequent upon the accident, or great depres- 
sion from haemorrhage, it might be a question whether the 
operation should be secondary, intermediary, or primary. 
The general rule of operative surgery, is, I think, that pri- 
mary operations are to be preferred, as there is much less 
danger from the additional shock, than from complications 
that would probably arise later. Not only is there danger 
from septic infection, but the effort required to dispose of the 
dead tissue must be considered. Should only a portion, of an 



CHRONIC GANGRENE r 163 

extremity be involved, poultices might hasten sloughing, and 
portions of the slough removed as fast as they become 
detached. The raw surfaces left are to be treated as simple 
ulcers. Calendula being the typical remedy. If the surfaces 
are large, skin grafting will probably be needed. Septic con- 
ditions, should they arise, are to be met with Rhus, Arsenic, 
or Laeliesis. according to indications, as will be shown in a 
later chapter. 

Gangrene arising spontaneously, from embolism, as a result 
of inflammation, calls for different consideration. There is 
always a possibility of the process extending, by new thrombi 
forming, or breaking up of the original clot, the fragments 
lodging in other locations, and thus extending the area of 
devitalization, in a very irregular manner. When seen early, 
before the necrotic process has fairly begun, it is occasionally 
possible to break up the clct, by massage, the small fragments 
lodging in distant and smaller vessels, producing comparatively 
insignificant results. Arnica should as a rule, be given in 
these cases, as it often disposes of the clot in a very expedi- 
tious manner, and much attention given to position of the part 
and keeping up the temperature, with a view to establishing 
collateral circulation. Amputation is not, as a rule, to be 
thought of, in these cases, until the line of demarcation formSj 
and the extent of the process has been clearly indicated. 
Secale, and Arsenic, are occasionally indicated, for intercurrent 
remedies. As to the slough, in inoperable cases, it is to be 
treated in the manner indicated above. 

Chronic Gangrene. — This form of gangrene is radically 
different, in cause, semeiologv and significance from the acute 
form. It is spoken of as dry, cold, senile, spontaneous. The 
symptoms of this form are a slowly extending gangrene, often 
commencing in points other than the distal extremities extend- 
ing in both directions. The parts shrink, and become mum- 
mified, often looking like charred tissues; at other times they 
are more soft and pliable, but rarely, if ever swollen and suc- 
culent. There may be sloughing, almost completed, and the 
process start up again, in some new direction, so that a line 

M 2 



x6^ ELEMENTS OF SURGICAL PATHOLOGY 

of demarcation is very irregular, and not to be relied upon, at 
all times, as indicative of an arrest of the process. The con- 
stitutional symptoms are severe, not acute, but indicating an 
exceedingly serious menace to life. 

The causes are changes in the blood-vessels, either athe- 
romatous degeneration, or calcification, such as are incident to 
old age, or to those whose habits have brought on a premature 
senility. The vessels becoming smaller and smaller, the 
circulation is slowly interrupted, thus the results will be differ- 
ent from a sudden closure, such as occurs in the acute forms. 
When the larger trunks are finally closed, some progress has 
been made, of course, in the necrotic process at more distant 
points. In all probability there are changes in the blood that 
predispose to coagulation, and yet such conditions are not nec- 
essary. The interruption in the vessel by the slowly increasing 
stenosis, and the loss of muscularity in the vessels so affected, 
are conditions that would readily determine coagulation. 

Prognosis is much more grave than in the acute form, inas- 
much as the condition is due to pathological processes that are 
of the most serious character. Cases in which a line of demar- 
cation is sharply formed, and no tendency is shown to extend 
beyond this, may be treated as acute gangrene. 

Treatment, in a sense, is expectant. That is, it is designed 
to arrest the progress, and later to get rid of the slough. 
Amputation is rarely indicated, as repair is uncertain, and 
gangrene of the stump to be feared. Notwithstanding, I have 
twice amputated the thigh, for gangrene of the leg, in old men, 
with good results, the patients living some years, and dying 
from causes unconnected with the gangrene, or the condi- 
tions causing it. The gangrene having become established, no 
matter to how small a degree, there is little to be done, as a 
rule, but to meet indications as they arise. When the condi- 
tion of the vessels is recognized early, it may be possible to 
avert the threatened danger by the use of appropriate reme- 
dies, and such adjuvant measures as would have a tendency to 
facilitate the circulation of the blood. Secale seems to be a 
remedy often er indicated than any other. Lachesis, Arsenic, 
or Baryta cafb. are credited with cures. 



XII— SURGICAL TOXEMIA 

There are conditions that may be considered modifications 
of the inflammatory process, some of them with constructive 
characters, and others destructive. Among the former we 
will find tumors stand as types; the latter will include all forms 
of toxaemia, having any relation to traumatism. The primi- 
tive classification of these processes is into septicaemia, and 
pyaemia, while the former may be divided into three forms or 
varieties, which have been given different names by different 
authorities. The differences being mainly in degree, however, 
it will answer our present purpose to ignore the secondary 
classification in this discussion. 

SEPTICEMIA. 

It is affirmed, with all the strength of recognized authority, 
that septicaemia, pyaemia, hectic, traumatic fever, and purulent 
infection, are convertible terms, indicating one and the same 
condition, perhaps, to a certain extent, different stages and 
degrees of the same morbid action. It would be the height of 
presumption, in one with such slender claims to notice as 
myself, to dispute a statement made with such positiveness, and 
coming from such unquestioned masters in our art as Bryant 
and Billroth, were it not for the fact that the surgical pro- 
fession are not by any means an unit on the question, and 
names of equal prominence are arrayed on either side. That 
there is a marked difference in etiology, semeiology and path- 
ology, between septicaemia and pyaemia, none can or do deny. 
As homoeopaths, it is proper for us to enquire if these points of 

165 



1 66 ELEMENTS OF SURGICAL PATHOLOGY 

difference are not indicative of distinct forms of morbid action, 
and be careful that we do not give adherence to either party 
in the controversy until we have well studied the question, and 
are prepared to give a reason for the faith that is in us. 

Septicaemia, translated liberally, means "putrid blood," 
and is a condition of impaired nutrition supposably due to the 
absorption of putrefying organic matter, whether derived from 
necrotic processes in the neighborhood of the focus of absorp- 
tion, or introduced from without in the form of minute germs 
and organisms. There are two essential factors that must be 
present in every case, viz., a wound or a traumatic condition 
simulating one, and septic material present for absorption. 
The phenomena can never be established spontaneously in an 
uninjured organism, and going more deeply into the subject 
of etiology, I risk the assertion, that there must be a physio- 
logical change in the part, if not the whole organism, anteced- 
ent to absorption. A wound in healthy tissue, the individual 
being in an ordinary state of health, does not have anv patho- 
logical significance whatever; the wound itself is not only 
purely accidental, but at once calls into activity forces that are 
designed to meet just such exigencies, and hence while a con- 
dition of hyper-nutrition is set up, it is strictly physiological. 
Now whether the wound be open to the air or subcutaneous, 
exercises a very important influence on the result, so far as 
absorption is concerned. An open wound passes through the 
following routine in a normal process of healing: First a 
stage of so-called quiescence, in which there is an elimination 
of foreign material, whether it be devitalized organic particles, 
or material from without. Second, a stage of active repair, 
during which lymph is thrown out, new tissue is organized, 
and new blood vessels formed. In both of these stages, it 
will be observed, the physiological phenomenon is one of 
excretion, largely if not entirely. There is comparatively 
little if any absorption, because there is little if anything to be 
absorbed. It is manifest, therefore, that if excretion is the nor- 
mal function in repair, there must be some notable alteration 
in function when absorption occurs. Hence, it is evident, 



SEPTIC-3EMIA 167 

septic absorption is the result of a local change of function, 
pathological in character, and that must be put into operation 
before the absorption can occur. 

In the case of subcutaneous wounds, to some considerable 
extent, different conditions obtain. There is usually much 
exudation to be disposed of, blood or serum, and perhaps 
devitalized organic particles, depending upon the character of 
the injury. Even here, in a healthy functional state, absorp- 
tion is restricted to aseptic matter, devitalized and foreign 
material being ejected if an outlet can be found. In the 
absence of an outlet, an abscess may form; if absorption of all 
the exudate does not occur, it undergoes fibrinous organization, 
as is seen in meningeal effusion in the cranium. As a matter 
of fact there must be, therefore, even in the case of subcu- 
taneous wounds, some perversion of function before the con- 
ditions essential to septic absorption occur. The various 
tenotomy operations are cases in point, where there is much 
exudation, even extravasation, and yet repair is secured with- 
out inflammation. 

It would be an interesting study to enquire what is the 
change that thus converts an excreting surface into an absorb- 
ing one, but our absolute want of definite knowledge, and the 
conflicting nature of the theories offered, forbids such a dis- 
cussion at this time. We must concede the facts as they 
exist, that prior to absorption there must be a recognized 
change in local functional activity. 

Similar conditions exist in connection with what might be 
called accidents, even while there is no true w r ound present. 
We find more cases of septicaemia in general practice amongst 
parturient patients than any other, in which the open sinuses, 
and torn vessels simulate an open wound. Here again the 
function of the part is notably excretory, and, if memory 
serves me, there is some change in bodily function prior to 
the actual suppression of the discharges. In either case, how- 
ever, whether medical or surgical, the reestablishment of 
excretion, at once disposes of the septicaemia, unless too much 
time has been lost, and the fact seems to throw much discredit 



j6S elements of surgical pathology 

upon the authenticity of the facts upon which the doctrine of 
antiseptic surgery is based. But of this I will speak at 
length later, simply remarking at this time, as a fact to be 
borne in mind, that repair practically ceases the moment 
absorption actively commences. Repair means, abundant 
exudation of formative elements, and active cell proliferation; 
with a cessation of exudation, there is a lack of material out 
of which tissue is made, and repair cannot be carried on. 
Absorption also means this: There is no local change, except 
in obedience to reflex action at the centres of life; it does not 
come from external agencies (except as exciting causes), but 
from internal, systemic, functional abnormality. 

The effect of this absorption of septic material is to induce 
local inflammation, consequently disturbed nutrition; and sec- 
ondarily, general febrile disturbance and mal-nutrition. In 
pursuance of my present plan, it may not be necessary to go 
into the question of minute pathology, it w r ill suffice to call 
attention to the fact that septicaemia represents a condition of 
chronic inflammation. 

Simon {Holmes* Syst. of Surg., i., p. 60), thus speaks of the 
retention of putrefiable organic substances: "It needs not to 
be argued that the due defecation of the body is as important 
to it as its food. But in the present context the student will do 
well to reflect particularly on the immense amount and com- 
plexity of those molecular changes which silently and almost 
secretly minister to the defecation; how the material of every 
acting organ changes in its every act, by waste, as also by 
renewal; how products, which eventually appear more or less 
oxydized and altered in the breath, and sweat, and urine, and 
faeces, are uninterruptedly being thus disengaged, and, as it 
were, moulted from the living textures; how, while the body 
grows its healthy growth, these declining products are inces- 
santly merging themselves in the blood which washes past their 
source — -merging themselves in it, not as urea and carbonic 
acid, and excretion, but in impermanent forms infinitely more 
complex. Reflecting on these many results of textural drain- 
age, each with its own protean constitution of effete devitalized 



SEPTICEMIA 



169 



material, the Student will easily conceive how important a mal- 
nutrition it may be for an}- of them to remain stagnant among 
the living substances, instead of continuing its progress to 
excretion." Does not such a suggestion as our author has 
given, carry with it a conviction that with excretion practically 
increased, by the retention of its products, even while it is 
actually suspended, as far as normal function is concerned, the 
state of septicaemia must represent one of exaggerated waste? 
Whatever the true cause may be, the symptoms and cause 
of septicaemia are always of a chronic character, and are as 
follows, in a typical case: There is a sudden rise in tempera- 
ture, with other symptoms of fever, restlessness, and perhaps 
a chill or simple suggestion of chilliness at the commencement 
of the fever; the secretions of the w r ound, or the discharges 
from states simulating a w 7 ound, become more and more scanty, 
and in extreme cases cease altogether, or nearly so; the part 
becomes more or less swollen and cedematous; the course of 
the lymphatics is marked on the skin by red lines ; the nearest 
gland or system of glands become enlarged and tumefied, and 
may proceed to suppuration. Emaciation is characteristic, 
with disturbance of digestion, anorexia and often nausea and 
yomiting, or a simple disinclination for food. In the case of 
puerperal septicaemia or lesion in the near neighborhood of 
serous surfaces, there is likely to be inflammation of such 
membranes; but in other cases, excepting in very aggravated 
instances, the mischief is confined entirely to the lymphatics. 
In the majority of instances' the morbid manifestations cease 
with the suppuration of the glands; but in others it may extend 
to the veins, and pyaemia result. The symptoms may be 
studied in two groups, the general and the local. In the 
former, the nightly rise of temperature, continued fever, pro- 
gressive emaciation, and gastric disturbance occupy the first 
rank. The variations in temperature are rarely greater than 
one or at most two degrees, but at no time, except when a 
fatal termination is to be feared, does the mercury indicate 
anything below the normal standard; constant elevation, with 
nightly rise, is the prevailing characteristic. The pulse is 



^o ELEMENTS OF SURGICAL PATHOLOGY 

usually above an hundred, prevailing weak and compressible, 
the strength of the pulsations not increasing with the rise in 
frequency. There are no distinct chills, in fact there may be 
nothing Suggestive of chill from first to last; usually, however, 
there is a rigor at the commencement of the process, and at 
irregular intervals afterward, as when suppuration of the glands 
occurs. Emaciation is a marked symptom from first to last; 
in grave cases the patient seems to melt away, visibly losing 
weight in the interval between the physician's visits. The 
mind may become impaired, not the apathetic state of pyaemia, 
so much as the more active forms of delirium, aggravated at 
the periods of maximum heat. There may be sweat, but 
oftener, the skin is dry and harsh, with a peculiar pungency 
felt on application of the hand. The bowels are inactive, 
unless in the later stages of threatening cases, when diarrhoea,, 
more or less involuntary occurs, The urine is scanty, loaded 
with urea, perhaps albumen, sometimes an evacuation of the 
bladder occurring but once in twenty-four hours. The whole 
array of symptoms closely resemble many of the ordinary 
forms of continued fever, and present nothing pathognomic 
taken apart from the local state. 

Smith [Operat. Surg., p. 68) says: "When the condition 
arises from absorption from a wound, the- earliest indication 
will be a suppression or alteration of the discharges, united 
parts fall asunder, and the edges of the wound become some- 
what everted." The following case may assist in individualiz- 
ing septicaemia. 

Case. — H. T. B. Was called April 17, 1879, by m y friend. 
Dr. J. D. Craig, of Detroit, to visit a case with him that 
might call for operation. Found the patient, a young man of 
twenty-six, with an enormously large testicle, on the right side, 
with a slight discharge of pus through two small punctures in 
the scrotum. Learned that he had been a victim of congeni- 
tal hydrocele, and had undergone two tapping operations. 
The last operation not affording relief, and no subsidence of 
the swelling following, in fact, a sudden and notable increase 
in size was observed — a seton was introduced, and retained for 



SEPTICEMIA 171 

a number of days. Diagnosis, traumatic cystic sarcocele, due 
to injury to the testicle in the second tapping, and the intro- 
duction of the seton, which was subsequently found to have 
passed directly through the testicle. His condition was bad; 
cold, clammy perspiration; rapid, weak pulse; pale, drawn 
face: frequent rigors; slight diarrhoea, partially involuntary, and 
a peculiar sweetish odor to the exhalations. Septicaemia was 
recognized, and immediate removal of the testicle counselled. 
Accordingly, on the following day, the gland was removed, 
found to contain a pint of horribly offensive pus, which had 
burrowed up the spermatic canal for some distance, the ingui- 
nal rings being large enough to admit the ringer easily. 
Prognosis guarded. Had a smart secondary haemorrhage, in 
about six hours, due to the hypertrophied condition of the 
parts, and another slight one later in the night. He became 
much distressed with abdominal pains, frequent sighing res- 
piration, wanted to be fanned occasionally, and all the septic 
symptoms much increased. Gave Carboveg. 30, a dose every 
hour. Dr. Craig gave, also, an occasional dose of Arsenic 
He soon improved and made a good recovery. The indication 
for the Carbo veg. was the sighing respiration, and the accu- 
mulation of flatus, giving pain, which was mitigated when dis- 
charging it. 

Finally, the morbid action, as far as objectivity is concerned, 
a most important diagnostic fact is found in the restricted ter- 
ritory involved, rarely extending beyond the first gland impli- 
cated, or exceeding the limits of the part first invaded (if an 
extremity), or, under more unfavorable circumstances, extend- 
ing to the other side of the body. The character of the 
objective group of symptoms, therefore, might well give color 
to the assertion that the process is a purely local one, hence 
entirely dependent upon external agencies. On the other 
hand the subjective group are as distinctly in favor of its consti- 
tutional origin and nature, which, if established, must be fatal 
to the so-called ' ; antiseptic" doctrine and practice. The objec- 
tion we find made, that the constitutional symptoms are "or 
may be" (it is more carefully put) of a purely secondary 



172 



ELEMENTS OF SURGICAL PATHOLOGY 



character, coming on after the local mischief has become estab- 
lished, is very easily met: The Jirst symptom of septicaemia is 
the sudden rise in the temperature, followed, usually after 
some hours, by the local changes noted above. There may 
be cases in which the apparently simultaneous appearance of 
the two groups might cause embarrassment in determining 
priority; but the remembrance that the nerve centers must be 
impressed to produce the constitutional disturbance will point 
out the necessitv for the lapse of an appreciable period of 
time after infection, which can only be shortened by the unusual 
energy of the local excitant, or a phenomenal receptivity on 
the part of the patient. The first disturbance being a varia- 
tion in temperature might well be overlooked unless the ther- 
mometer was carefully used at short intervals. 

There can be little doubt that modifications of inflammation 
plav a very important part in the production or maintenance 
of septicaemia. The primary alteration in the blood; the exag- 
gerated waste; the retention of exudation: the lymphatic 
derangement, and many other prominent characteristics of in- 
flammation furnish suitable conditions for bothj.he production 
of septic material and the absorption thereof. I think, there- 
fore, to repeat an earlier proposition, that it can be agreed 
that septicaemia represents a profound vital disturbance which 
results in the suppression of excretion and establishment of 
absorption, without essential relation to external conditions, 
excepting as the latter may modify general nutrition. This 
theory is in perfect harmony with the prevailing ideas of etiol- 
ogy in the Homoeopathic school, and would seem to be well- 
sustained, apart from this, by a proper consideration of the 
admitted phenomena characterizing the state. Let us now 
examine the grounds upon which an opposite theory is based. 

The assumption, for it amounts to little more, upon which 
the antiseptic theory is constructed, is that septic infection is 
due to the entrance of micro-organisms into the body, through 
open wounds of more or less magnitude. It is not necessary 
to argue the doctrine of bacterial pathogenesis again; the 
matter has received attention elsewhere. At this time, how- 



SKl'TLC.KMIA 



173 



ever, the fact must be recalled that in all cases of traumatism, 
the surfaces of the wounded tissues are swarming with bac- 
terial forms of all kinds, and the same condition is found on 
unwounded surfaces. Indeed, not only is the presence of 
these organisms not incompatible with health and normality, 
but they may be considered essential to it preservation. But 
dismissing this discussion now, the fact must be emphasized 
that for therapeutic purposes it is a matter that admits of no 
argument. Admitting that the bacterial infection is the true 
cause for septic infection, either they must be prevented from 
entering; or having entered, they must be destroyed; or, if 
this is impossible, the consequences must be met by indirect 
methods. There are no means known to science to keep 
them out of the wound. Therefore dismiss that. They can 
only be prevented from doing mischief by keeping up the 
normal resistance of the tissues. This we cannot do with 
germicides, because the tissues suffer just as the microbes do. 
The indicated remedy is the best " germicide." Evil conse- 
quences having resulted, the ordinary germicidal treatment is 
impossible, and we are powerless, unless we have remedies 
at hand that will establish healthy resistance. It is true that 
a modified bacterial theory is not incompatible with an enlight- 
ened therapeusis, yet there seems to be a very general admis- 
sion that the state of the tissues determines the result as to 
infection. The rational conception, it seems to me, would be 
that anything which promoted repair, would be the proper 
germicide; in other words, it is not a germicide, properly 
speaking, that we need, but a vulnerary. The fact must be 
admitted — admitted because it has all the authority of actual 
demonstration — that a cell-destroyer cannot be a cell-producer; 
hence germicidal and vulnerary properties are antagonistic. 
Lastly, how do we reconcile the conflicting character of 
statistics, not only -pro and con as to antiseptics, but as to the 
different agents in the alleged antiseptic group? The answer 
is equally easy, but minute demonstration is unnecessary. 

That statistics are often untruthful, but undesignedly so, 
Ashurst has shown in (Inter. Encyl. Surg.} debating the 



i74 



ELEMENTS OF SURGICAL PATHOLOGY 



questions relating to different methods of treating the stump 
after amputations, by the citation of an immense number of 
reports, that taken singly would prove very conclusive in any 
of the categories, but when analyzed and rearranged, by one 
indifferent to the result, vary greatly. Thus a writer will 
tabulate hospital reports of amputations in general, and get- 
ting the ratio of mortality will compare it with his report, 
perhaps of selected cases, and find a ratio immensely in his 
favor. Now analyze the hospital report: As given by our 
author it will simply state, number of amputations, so many; 
recoveries, so many; deaths, so many; ratio of mortality, so 
and so. No attention is given to questions of sex, age, 
whether for disease or accident; the size of the part, previous 
bodily condition of the patient, whether performed primarily, 
intermediately, or secondarily, and the kind of operation all 
exercising important bearing on the result. Thus analysed, 
the statistics have a very different significance; to make our 
author's tables of any value, he must compare his cases with 
exactly similar cases, in all particulars, and then, as the ques- 
tion is on the merits of dressings, the time consumed in treat- 
ment must enter into the enquiry as well as the mere question 
of mortality. If this is true of statistics of operations, how 
much more is it true of methods of treatment? Let us secure 
an accurate report of a number of selected cases, submitted to 
one kind of treatment, with reference to protection from septic 
infection and length of time consumed in completing repair, 
and compare it with a similar list, embracing the same con- 
siderations, of cases treated by another method. As far as 
Ashurst has gone, in this comparison, he finds the differences 
are small indeed, so much so that the question of selection of 
a method is after all determined more with reference to 
convenience and facilities at command than any therapeutic 
consideration. In other words, no matter whether you use 
open air, water, dry earth, full " Listerism," the method of 
Guerrin, or Iodoform, about the same length of time is con- 
sumed, the facility of union, and the same good results, taking 
cases as exactly similar as possible for a guide and comparison. 



SKl'TU'.KMIA 



175 



The presumption is very fairly to be stated, that in a large 
proportion of injuries and wounds from operation, it requires 
very active and energetic interference to retard or modify 
repair, a good result being the rule even when the case is left 
entirely to nature. Indeed, there can be no question that 
very many cases have resulted disastrously that might have 
made a good recovery had they not had surgical care. 
President Garfield's case, I fear, was one in point. 

From a therapeutic point of view, we have two problems 
presented for solution, one of prophylaxis, and one of treat- 
ment if the former fails. The first indication is met, in plac- 
ing the body in the best condition obtainable, as to nutri- 
tion, and particularly to facilitate, by all means in our power, 
the prompt closing of the wound. Of course we are engaged 
in studying this condition as it is presented to the surgeon. 
The wound is to be treated, as long-established homoeopathic 
principles, tested by hundreds of practitioners, have proved the 
most desirable. Pain is to be arrested or controlled as an ele- 
ment of danger, apart from all other considerations, on account 
of the nervous disturbance and exhaustion induced thereby; 
Hypericum seems to accomplish all that could be desired in 
this direction. Arnica, when there is effusion of blood to be 
disposed of; Calendula, when there is much loss of substance, 
and the gap to be filled by granulation ; Stafihysagria when the 
incision is smooth, the wound can be closely approximated, 
and there is no foreign matter to be expelled; and Ledum or 
Stramonium, when injuries to the nerves are the prominent 
lesion, and there is reason to fear tetanus, are remedies with 
which we are all familiar, and which have a reputation amply 
sustained when put to the clinical test. With a proper use of 
such precautions, and a mechanical treatment of the wound in 
accordance with common and well-known surgical principles, 
there can be small opportunity for septic trouble, particularly 
where proper nutrition is attended to. There can be no need 
for germicides, as a very simple and familiar illustration will 
show. Consider the method of repair of wounds in animals. 
From time immemorial the rapidity with which wounds in dogs 



1 76 ELEMENTS OF SURGICAL PATHOLOGY 

heal has been cited as an illustration of typical repair. It was 
this that led to the many attempts to form a scab artificially. 
Yet, consider, there are no antiseptic precautions taken, and 
never have been, in treating wounds in animals, and the most 
ignorant observer has learned to leave them alone, to " nature," 
as they phrase it. The conditions are such as we would sup- 
pose are peculiarly favorable for septic trouble if admission of 
germs is the cause, and the contact with dead organic matter, 
furnished by the inspissated lymph, dried blood, matted hair, 
and extraneous dust, should add to the danger ten-fold. I am 
not aware of a single example of septicaemia in the case of 
wounded animals, and we know, also, that wounds heal with 
remarkable facility; in fact, when death occurs from injury, it 
is nearly always from the primary lesion; rarely, if ever, from 
secondary affections. 

Treatment is quite successful if the case is well understood 
and the character comprehended early. Moderate stimulation 
must not be neglected, and external temperature attended to. 
The first indications of resolution, when there is an open 
wound, will be a return of the discharge, or an improvement 
in its character; otherwise there will be an improvement in the 
pulse, the tongue will become moist, some interest will be 
taken in what is going on around and the skin will feel more 
natural. The remedies in which experience has given me the 
greatest confidence, are Arsenic, Lack., and Carbo veg., per- 
haps Rhus may be useful in some instances. 

Arsenicum. — This remedy takes the first rank, in my prac- 
tice, and I have seen very few cases in which it was not indi- 
cated at some stage of the treatment. The shorter the incu- 
batory period, and the greater the severity and rapidity of 
development, the stronger the indications. The more char- 
acteristic symptoms are as follows : Great prostration, with an 
apathetic condition of the mind, whilst the body is very rest- 
less; diarrhoea profuse, watery, and scalding; oedema, or 
anarsarca of the lower extremities; thirst for cold water, but 
vomiting after, drinking. 

Lachesis. — Hughes {Pharmacodynamics) , considers this a 



r\\KMi.\ ^7 

first class remedy whore pyaemia is also developed. My col- 
leagues have on several occasions, verified its value. It is 
chiefly indicated by the apathy peculiar to the condition, par- 
ticularly when there is bodily lassitude as well; the skin is 
dark colored, mottled, but little oedema. In one case there 
was a discharge of black fluid blood, from the wound, as in 
snake-bites, and whilst the patient ultimately died, the symp- 
toms were promptly improved by this remedy. 

Carbo veg. — The symptoms calling for this remedy, are 
chiefly visceral. There is bloating of the abdomen, rolling of 
flatus, great internal heat and much prostration with sighing 
respiration. The patient requires to be fanned to give him air. 

Rhus may be of service when the skin is chiefly affected^ 
running into an erysipelatous state, with great bodily restless- 
ness, and general typhoid conditions. 

PYAEMIA. 

We have found, or may assume it, that septicaemia repre- 
sents a disturbance of nutrition chiefly or entirely in connection 
with the lymphatics ; it may now be stated, that when the dis- 
turbance reaches the blood, with a tendency to the formation 
of thrombus, through an increased "fibriniferousness," as 
Simon calls it. we have reached a stage far in advance of that 
represented by septicaemia, but which has only a partial rela- 
tion thereto, inasmuch as this "thromballosis," may appear 
entirely without such relation, appear ab initio, as it were. 

Pyaemia literally means " pus in the blood," or purulent 
blood, and is a term born at a time when suppuration was very 
differently appreciated from what it is to-day. It was sup- 
posed that pus found entrance into the circulation, and was 
carried to different parts of the body forming neuclei for abscess 
wherever lodged. The main features of pyaemia, as serving 
to distinguish it from septicaemia, both in cause, progress and 
termination, are its acute character, regularity of the rigors, 
and formation of abscesses, in various and widely separated 
parts of the body, known as multiple or metastatic abscess. 

In the large majority of cases, the first symptoms of septi- 

N 



178 ELEMENTS OP SURGICAL PATHOLOGY 

caemia appear within three days from the reception of injury. 
In cases of traumatic origin, pyaemia rarely, if ever, appears 
until after septicaemia is well established, appearing as a sequel 
to that process. But the symptoms are so marked, and there 
is such- a radical change in the character of the malady, that 
none need be led into error. The temperature, it has been 
shown, in septicaemia is never below normal, unless a fatal 
issue is imminent, and does not run very high above. In 
pyaemia, on the contrary, there is a marked want of periodic- 
ity in these fluctuations; in the course of a few hours there 
will be a variation of eight or even more degrees, giving a 
characteristic appearance to the chart. It will fall, w r ith no 
premonitory indications, a degree or two below normal, and in 
a few hours will shoot up to five or six above; instantly, 
almost, drop down below starting point, fluctuate between that 
and a degree or two above, and then shoot up again, in favor- 
able cases not reaching its former altitude. The long needle- 
like marks in a pyaemic thermograph have become diagnostic 
with me, and once, if not oftener, the first appearance of this 
kind enabled me to lead the case to a successful issue by 
anticipating treatment some hours before any other physical 
signs were present. The commencement of the process is 
usually, indeed always, introduced by a chill or rigor, followed 
immediately by a considerable rise in temperature. The chills 
are repeated at intervals, at times as regularly as in intermit- 
tent fever, at other times irregularly. The diagnosis of pyae- 
mia is confirmed in proportion as the chills are regular or 
frequently repeated. Fever of a continued character appears, 
often having many of the characteristics of hectic; there is 
much mental disturbance — rarely an active delirium, but an 
apathetic or semi-comatose state; the face has a peculiar 
bronzed or muddy appearance; emaciation is considerable and 
rapid; urine is scanty, bowels inactive, skin dry and the teeth 
covered with sordes. The eyes look dull and lifeless, bed 
sores may appear, and the exhalations and breath have a 
peculiar sweetish, nauseous odor. So far the symptoms are 
common to many forms of asthenic fever, but more character- 



PWEMIA 179 

istic ones arc not wanting. There are visceral complications, 
early in the case, particularly in the liver, spleen, and lungs; 
later other organs may suffer, and post-mortem examination 
reveals numerous abscesses scattered through the substance of 
the parts involved. These collections of pus are called metas- 
tatic abscesses, and are the central symptoms of pyaemia, with- 
out which a diagnosis cannot be made, and with which the 
diagnosis is verified. Accordingly all those who recognize a 
difference between these surgical toxaemia have devoted much 
attention to the study of the etiology of this form of abscess. 
To show the difficulties under which the opposite party labor, 
let me call attention to the remarks of Dr. Delafield [Inter. 
Encyc. of Surgery \ i., p. 204), one of the latest writers on 
the subject: "But as Koch says, the names pyaemia and 
septicaemia no longer express what was originally meant by 
them. For pyaemia does not arise, as was formerly supposed, 
from the entrance of pus into the blood-vessels, nor is septicae- 
mia a putrefaction of the living blood. These have only 
remained in use as general names for a number of symptoms, 
which must probably belong to a series of different diseases. 
In this article the word pyaemia will be used as a general term 
to designate the entire group of cases." And again on page 
207: "It is impossible to describe the symptoms and lesions 
of pyaemia, as we can those of a definite disease. The best 
that can be done is to enumerate the different conditions 
which are commonly spoken of under the name of pyaemia, 
and to describe the symptoms and lesions which belong to 
to each condition." The result of this attempt, as illustrated 
in the chapter from which the extracts have been made, has 
been to leave the student in a state of hopeless confusion, and 
which would well-nigh paralyze therapeutic efforts if more 
rational treatises were not obtainable. When the time arrives, 
as it is hoped it ma}*, when our knowledge of drug action 
will extend from the most remote prodromal lesion to the 
fully developed malady, accuracy in our practice can only be 
obtained by possessing equally exact knowledge of morbid 
action. It ill becomes us, therefore, to ignorantly and unques- 

N 2 



T 8o elements of surgical pathology 

tioningly, adopt all the teachings of the day, particularly 
when they are avowedly designed to simplify nosology by 
grouping allied conditions under a single name. It is our part 
to individualize morbid phenomena, to a far greater extent 
than has ever been the case hitherto. Let us, therefore, 
enquire at some length, the meaning and origin of metastatic 
abscess. 

All observers recognize the fact that the first gross lesion, 
as regards the condition of the blood, is the formation of 
thrombus or clot in the veins. There is little question that 
this thrombus is due to two factors, first an increased coagula- 
bility of the blood, and second an excitant to such coagulation. 
The question of increased " fibrinif erousness " of the blood is 
practically impossible of solution in the present state of knowl- 
edge. Some writers doubt if fibrine is a normal constituent 
of blood, a merely accidental ingredient. An objection to 
this theory, it seems to me, is found in the fact that blood 
coagulates readily under all circumstances, when drawn from 
healthy veins, the coagulation being due to the fibrine con- 
tained therein. What is the fibrine? Is it representative of 
tissue-making elements, or of retrograde metamorphosis? A 
suggestion of a plausible elucidation is found in the fact that 
blood increases in coagulability in proportion to the increase 
in the intensity of the inflammatory process. Inflammation 
representing a state of exaggerated waste, excessive produc- 
tion and deficient organization, the presumption is entertained 
by many of our pathologists, that fibrine is the result of post- 
perfection. Now inflammation, arising idiopathically, repre- 
sents one of contrary states of the blood, poverty or plethora, 
and either state, whilst practically contradictory, furnishes the 
same elements favorable to coagulability. In the former we 
have plastic material which the forces of organization are 
inadequate to appropriate; in the latter, we have an excess 
of these elements beyond the need of the body. In either 
case there is, therefore, a preponderance of fibrine, and a con- 
dition of the blood favoring coagulation on proper incitement. 

The coagulability being provided we have next to search 



TY.KMIA 181 

for the probable exciting cause. We find this three-fold: 
The introduction of a nucleus into the current of the circula- 
tion: anatomical factors relating to the arrangement and dis- 
tribution of the vessels; and physiological abnormalities, par- 
ticularly with reference to the phenomenon of circulation, as 
retardation, remittency. or some similar disturbing force. 

There can be no doubt that the continuance or unusual 
energy of septicaemia may introduce into the blood particles 
of foreign material that act as a nucleus for coagulation, apart 
from any specific or septic character they may possess, solely 
in obedience to mechanical laws. Experiment has shown 
that such material is at once encapsulated by the fibrine of 
the blood, probably as a conservatiye process, but practically 
it enlarges the probabilities of thromballosis by increasing 
materially the size of the foreign body. Pus may, also be 
introduced into the blood-current and, without specificity, 
induce coagulation precisely as an}* foreign body would. 
Now it matters not whether we consider pus to be a product 
of the blood, a proliferation of connective-tissue corpuscles, or 
a return of formed tissue to the embryonic state; under each 
and all of these conditions — and they may all be accepted as 
parts of the whole truth of suppuration — the pathognomonic 
element of the pus is the cell, which has been quite conclu- 
sively shown to be a dead leucocyte. To repeat what has 
often been said, the corpuscular part of pus is not diagnostic 
until all amoeboid properties are lost; as long as these continue, 
the cell, taken apart from any other characters of the mass in 
which it is found, and without knowledge of its source, is a 
leucocyte and nothing more. It is only when dead, spherical, 
granular, and perhaps fatty, that, under the above hypothet- 
ical conditions, the observer can unhesitatingly pronounce it a 
pus cell. Now this being true, such a cell is as much a for- 
eign element in the blood as any other dead organic particle 
derived from without, and will become encapsulated and form 
a nucleus for a thrombus just as readily. Suppose, again, that 
the pus-cell is found to be intervascular, with no eyidence of 
suppuration outside of the tissue of the vessel, as may occur in 



1 82 ELEMENTS OF SURGICAL PATHOLOGY 

suppurative phlebitis, how, we may ask, did it find entrance 
to the blood? It was formerly taught that the venous endothe- 
lium, the intima, furnished pus as a result of inflammation. 
Later we were told, by Simon, Cali.ender, and others, that 
" the lining membrane of the veins rarely inflames and never 
suppurates." This is astonishing doctrine to come from those 
who yielded full credit to the teachings of Cohnheim. Any 
vascular tissue can become inflamed, and suppuration is a 
normal sequence to inflammation. To make this stronger it 
can now be asserted that all tissue is vascular, and the blood 
comes into direct relation with every part of the organic body. 
The pus-cell in the current of the blood can be derived from 
either the endothelium, or the blood itself bv an accidental 
destruction of the white corpuscle. From a consideration of 
these facts it seems to be a legitimate conclusion that the 
mucleus of the clot may be inter- or extra-vascular, both as 
regards character and source; that is, it may be entirely septic 
or a product of suppuration. 

This brings us to the next point, the anatomical arrangement 
of the vessels as favoring coagulation. It has long been 
observed that with the heart as the center of the propelling 
force of the blood, there is a demand for some resistance to the 
force and rapidity of the current in some regions, and for a 
diminution of resistance at others. Thus the closer the vessels 
are to the source of power, the greater the demand for resist- 
ance; and the farther they are removed from that center the 
less resistance there must be. The realization is found in the 
arrangement of the angle at which collateral branches are 
given off from the main trunk; being at right-angles near the 
heart, the angle becoming more and more acute as the distance 
from the heart increases. 

While this arrangement is admirable as long as the condi- 
tions of the blood and circulation are normal, when pyaemia or 
thrombaliosis sets in it becomes an element of danger. Con- 
ceive a current of blood flowing in a comparatively sluggish 
manner, as it must do in the peripheral veins, with its plastic- 
ity so abnormally increased that it seems, as it were, to be in 



P Y.K.MIA r 83 

search for an excuse for coagulation, coming in contact with 

an impediment like the wedge-like form of the point of bifur- 
cation in a vessel, as occasionally is found where a vein runs 
into a double one; even the valves are impediments. At once 
the excuse is found, and a layer of fibrine is deposited, conhnu- 
allv added to from the constant stream of blood passing over 
it. until a clot is formed. Hence the focus of thrombus 
becomes a matter of moment. 

Escaping this danger, the blood still being in the fibrinous 
condition essential to pyaemia, there is still a third way in which 
coagulation can occur, through physiological insufficiencies. 
Anything which retards the force or rapidity of the circulation 
must, on clearly understood physical principles, furnish the con- 
ditions for coagulation; thus shock, coma, and haemorrhage 
will weaken or suspend the heart's action, playing an import- 
ant part in causing pyaemia. 

In some one or all of these ways, therefore, thrombosis 
occurs, and under any or all circumstances there can be no 
question of the vital or intrinsic origin of pyaemia. There is 
no question here of bacteria, or the influence of arly organic 
forms from without. The process, from first to last, represents 
a species of morbid action in the true sense of the word. 

I have now accounted for the formation of the clot as the 
initial lesion in pyaemia, and it is next to be enquired what rela- 
tion multiple abscess has thereto. We must recognize the fact, 
in the first instance, that multiple abscess is not an invariable 
result of thrombus, whilst it is essential to the establishment of 
pyaemia. The clot may be of such a firm texture and perfect 
organization that the vessel is completely and permanently 
occluded. In consequence of this the vein may become oblit- 
erated, or abscess form on the distal side of the clot. When 
the latter, the clot may become gradually loosened, and either 
a channel formed for the passage of the blood, and thus the 
circulation becomes reestablished, or the clot carried on further 
in the current of the blood. These are the most desirable ter- 
minations. 

Again the suppuration may loosen the clot so that it is dis- 



184 



ELEMENTS OF SURGICAL PATHOLOGY 



charged with the contents of the abscess. In other cases, and 
under favorable circumstances, the clot being small and unat- 
tached, it may be carried into some of the arteries, after its 
passage through the lungs, and ultimately induce embolism; of 
course the consequences now will depend upon the vessel 
plugged up. These, whilst among the rare and infrequent ter- 
minations of thrombosis, are not at ail hypothetical, and may be 
considered on the whole, rather desirable. Should it be pos- 
sible to definitely locate the clot, in a superficial vessel, the ques- 
tion would arise how should it be disposed of; by an attempt at 
fixation, or dispersion? Either disposition presents its peculiar 
dangers, but fixation seems to be rather more desirable, as dis- 
persion may carry the fragments to regions in which the dan- 
ger would be greater, and multiple abscess is not so liable to 
occur. But this is not strictly w r ithin the line of our enquiry, 
as it is pyaemia and not simple thrombosis we arc studying. 

The clot is usually found at the point of division of a vein, 
oftener, perhaps, at the point of union between a deep and a 
superficial vessel, lying across what is practically a septum 
The clot acts as a nucleus for fresh accessions, chiefly as the 
calibre of the vessel is correspondingly diminishing and the 
rapidity of the flow of blood retarded. Should the lumen of 
the vessel become entirely filled, the clot becomes lamellated 
in arrangement, and quite regularly organized. If one of the 
accidents mentioned above does not now intervene, the clot 
begings to soften in the centre, extending towards the proxi- 
mal periphery? when the particles thus thrown off are carried 
along in the current of the blood acting as nuclei for fresh 
coagulae wherever lodging. 

In the ordinary form, how ever, the clot does not become 
organized, is loose and friable in texture, hanging over into 
each vessel, particles continually breaking off and moving 
along in the blood current. The particles furnished by the 
original thrombus, under either circumstance, are carried 
along from the smaller vessels to the larger, passing ultimately 
into the lungs or liver with the stream of venous blood, and 
either lodging in the minute vessels in the organs, or passing 



PYAEMIA 185 

out again into the current of the arterial blood. When the 
latter, embolism is quite sure to occur when the smaller arter- 
ies are reached, and the characteristic phenomena are produced. 
When the former occurs, which is the natural pyaemic history, 
the point of lodgment becomes the focus for localized inflam- 
mation, and minute abscesses form, which at once endangers 
the integrity of contiguous parts and furnishes innumerable 
nuclei for new thrombi. 

This represents in brief a history of the origin and course 
of a typical case of pyaemia. The most superficial reader and 
student can scarcely fail to note the wide dissimilarity from 
septicaemia. In short, apart from the fact that pyaemia often 
appears as a sequel to septicaemia (from the neuclei of the 
thrombus essential to the former being provided by the latter), 
apart from this it is difficult to establish any nosological rela- 
tionship. W T e found septicaemia, in a former paragraph, to be 
due to vital changes without necessary dependence upon 
external conditions and circumstances, and the same vital con- 
siderations pertaining to the etiology of pyaemia have now been 
shown. Yet the conditions of one are only secondarily related 
or similar to the other, and I am forced to conclude that those 
who speak of them as a unit do so from an unfortunate desire 
to simplify nosology owing to a want of a proper appreciation 
of the requirements of pathology as related to therapeutics. 

We find, also, that pyaemia may not, at all times, be consid- 
ered primarily a species of morbid action. Traumatism, by 
inducing haemorrhage, feeble circulation, and weakened heart's 
action fills all the indications. The resulting suppuration is 
only an unfortunate conservatism of nature which blindly seeks 
to remove impediments to her operations by thrusting them 
out of the way in the speediest manner possible. With a 
splinter in the flesh this process is harmless and proper; with 
a thrombus in the lungs or liver, when a deterioration of 
vital powers is superadded from traumatism, it becomes 
dangerous and wrong. The two conditions are alike; the dif- 
ference in result and significance being solely on account of 
location, which converts a natural conservative process into a 



1 86 ELEMENTS OF SURGICAL PATHOLOGY 

threatening morbid one. It is not seldom that we find this 
faint line of demarcation between physiology and pathology. 
The first and characteristic morbid feature in pyaemia, is the 
increased fibriniferous quality of the blood; after this the 
further manifestations are in obedience to patent natural laws. 
The following short comparison will serve to emphasize 
these points of difference, and effectually prove dualhy in these 
forms of toxaemia. 

Septicemia. Pyaemia. 

Chronic in character. I Acute in character. 

Local causes primarily. Primarily systemic. 

Essentially traumatic. May be idiopathic. 

Lymphatic absorption the prime j Venous thrombosis the essential 



factor. 
Regular and moderate febrile heat. 

No regular chills. 
No multiple abscess. 



lesion. 
Irregular and extreme changes in. 

temperature. 
Chills frequent or regular. 
Multiple abscess. 



Treatment. — Naturally the treatment is divided into hygien- 
ic and medicinal. Under the former head nutrition occupies 
the first place, both as prophylactic and curative. By afford- 
ing this the conditions of pyaemia are averted or modified, and 
later the consequences may be more easily repaired. In fact,, 
in many cases, exhaustion rather than any specificity in the 
morbid action is responsible for death. Nutrition does not 
include what are particularly known as " tonics," yet mild 
stimulation is of the greatest value. It is not my purpose to 
suggest any particular form or variety of nutriment, as each 
case must become, to a considerable extent, a ' : law unto itself.'* 
Milk, however, is of the first value, usually, to which may be 
added a small quantity of lime water. Palatability and readi- 
ness of assimilation must be the controlling considerations. 

Remedies must be selected with the greatest care. Unfor- 
tunately many of our text books are written with such want 
of accuracy, as far so nosology is concerned, that they are 
often worse than useless as guides, even dangerously mislead- 
ing. Although among the humbler in the brotherhood of 



PYEMIA 187 

writers. I acknowledge guilt in my own share in this, often, it 
may be said in extenuation, from copying the language of 
others in whom I then had confidence. For instance, Lack. 
is spoken of in all our text-books as a prominent remedy in 
pyaemia; Hughes, I think, was the first to recommend it in 
this connection. It may be that the secondary effects of ser- 
pent venom show increased plasticity of the blood, but it is 
well known that the primary effect is a remarkable fluidity, 
loss of coagulability. This would rather make it a remedy 
for septicaemia, and the error has arisen, if it is an error — from 
a failure to distinguish between the two conditions. 

Arsenic has done me good service in one or two instances, 
and from a consideration of their known action, Arnica, Be//.. 
Merc, and Hani., with perhaps Rhus, should be more or 
less useful. 

This concludes a study of inflammation with the sequelae 
and modifications that have the character of destructive morbid 
action. Before taking up morbid processes that are construc- 
tive in their essential characteristics, attention must be invited 
to the lymphatic, vascular, and nervous systems, all of which 
will be found closely related to causation in many of these 
forms of disease. 



XIII.— PATHOLOGY OF THE LYA^PHATICS 

Whilst true of all tissues and parts, to a certain extent, the 
lymphatic system rarely originates morbid action. Whenever 
functional changes are observed in these vessels, it is only as 
concomitant upon morbific action originating elsewhere, whilst, 
at the same time, they are the media through which irritants 
are conveyed from one point to another, and from the periph- 
ery to the center. Thus in syphilis, gonorrhoea, vaccinia, 
carcinoma, and a host of other diseases, the peculiar morbid 
principle is conveyed by the absorbents from the point of 
initial lesion throughout the body. Acting so frequently as 
mere media, and without manifesting any yielding to the mor- 
bific agent themselves, they occupy an anomalous and inter- 
esting position in surgical pathology, of which our want of 
accurate knowledge forbids thorough and competent study. 
In the few instances in which morbid phenomena seem to 
originate in this system, we "are still far from enjoying a satis- 
factory knowledge of the modus operandi. The brief space 
we are enabled to give to this subject, therefore, will be 
devoted to a study of inflammation of the lymphatic vessels 
and glands, and lrypertrophv of the glands. 

INFLAMMATION OF THE LYMPHATICS. 

Angeioleucitis, the term used to distinguish inflammation 
of the vessels from that of the glands (adenitis'), presents some 
peculiarities over the same process in other structures that well 
repays study. The chief features are. rapidity of develop- 
ment, moving in the course of the afferent vessels, and 
1 88 



,N, LAMMATION OF THE LYMPHATICS 



189 



rarely passing the fifrst gland it reaches, excepting in the case 
of some specific forms of disease. 

The Causes of lymphatic inflammation are often very 
obscure, even when evidently traumatic; many injuries, per- 
haps the majority of them, pass through all the periods of 
repair without any complication of this character. I am of the 
opinion that it is the absorption of septic material that oftener 
produces the complication, at least such has been the case in 
the few examples I have seen. Exposure to cold, is a frequent 
cause, as some think from an unrecognized change in the con- 
tents of the vessels. In other cases, and perhaps the majority 
of instances, specific diseases, or the introduction of an irritant 
locally is the undoubted cause. 

The irritant once operative the subsequent manifestations 
are very rapid, so much so that the only analogue is furnished 
by the rapidity with which conjunctivitis follows irritation 
from a foreign body in the eye. Mr. MooRe (Holmes' 
Syst. Surg-., in., 330) mentions a case in which the prick of a 
perfectly clean needle, set up an acute lymphatic inflamma- 
tion, w r ith pain and swelling of the glands, which ran its 
course and subsided within the "space of a few minutes." In 
the majority of instances the attack is evanescent, not as 
markedly so as the above, and leaves little behind it in the 
way of permanent change in the tissues. 

The Symptoms are characteristic, when the superficial 
vessels are involved; when inflammation occurs in the deeper 
structures it is doubtful if a diagnosis can be made, at least 
with any approach to certainty. As will appear later, glandu- 
lar enlargement is supposed to be invariably indicative of 
lymphatic inflammation; hence the swelling of a gland with 
no signs of superficial angeioleucitis, would point to an irrita- 
tion of the deeper vessels. Starting from the point of injury, 
or irritation, the skin will be marked by red lines, running in 
the course of the lymphatic vessels, rarely extending above 
the nearest joint. Thus in the hand, the lines will terminate 
in the wrist; higher up they may pass to the elbow or axilla; 
it is said they never pass beyond the latter point, but this 



j go ELEMENTS OF SURGICAL PATHOLOGY 

must not be construed to mean that the liability to inflammation 
of the vessels does not extend beyond this region; the vessels 
here pass deeper, and cease to be superficial. The vessels 
can rarely he fell, by tracing them with the finger, neither 
are they sensitive to such pressure. The part is swollen 
more or less, perhaps oedematous; the temperature slightly 
elevated; and there may be stiffness on motion. The inflam- 
mation maj T pass away? in a very short time particularly if 
the glands are involved, in which case they seem to take all 
the burden upon themselves, relieving completely the affer- 
ent vessels. Otherwise, which is of very rare occurence, the 
inflammation will run through the usual stages, and terminate 
as in other regions. When the vessel is destroyed, either by 
sloughing or ulceration, or agglutination of the walls, the 
lymph will collect at the point of occlusion, distending the 
tube like a cyst until, nnally, another channel is found, or a 
perforation will occur, the lymph being poured out. In one 
case, recorded in a journal now mislaid, the lymph was dis- 
charged upon the cutaneous surface, a lymphatic fistula 
being formed, which remained in existence many years. In 
other cases, a communication has occurred between the lacteal 
cyst and the kidney, bladder, or some urinary appendage, 
and chyle discharged in the urine. In still other instances, 
two of which have come under my notice, the chyle has been 
poured out into the abdominal cavity, producing what is 
known as ascites chylosus. Under any of these circumstances 
the condition may be considered as one of fistula. The effects 
are entirely dependent upon the location of the fistula. Thus, 
if the thoracic duct be occluded particularly high up, death 
must ensue, sooner or later. When in less important vessels, 
the effects are entirely dependent upon the loss of nutrition. 

There are other results, however, of occlusion of a lym- 
phatic vessel. The contents of a cyst may become inspissated, 
and either a cretaceous or lardaceous degeneration occur, per- 
haps remain as a permanent tumor, and perhaps undergo dis- 
integration and suppuration. 

The inflammation, it has been said, does not often extend 



INFLAMMATION OP THE LYMPHATICS 191 

bevond the nearest gland. This is unquestionably true of 
non-specific affections, or traumatic sequelae; but not so in 
specific contagion, particularly syphilis and carcinoma, when 
a whole chain of glands becomes affected. I presume an 
explanation may be found in a consideration of the signifi- 
cance of glandular swelling. 

Traumatism can only change the fluids of the bod}' by 
adding broken down tissue, or some chemical product of 
decomposition. It cannot, in other words, add any specific 
toxic influence. The glands are under these circumstances 
engaged in the act of elimination, an act that is perfectly consist- 
ent with their normal function. They enlarge because the work 
required of them is increased. In rare instances the work 
will be too great for the gland nearest the point of injury, 
and others beyond it, will become enlarged. If the efforts of 
nature are successful, the swelling will gradually disappear, 
and all irritation and inflammatory symptoms pass away. If 
unsuccessful, suppuration will ensue, an abscess form, and the 
material causa morbi may be thrown out in the discharges. 

In the case of specific disease, however, the conditions are 
widely different. Here it is not an elimination that is going 
on, but an absorption. The formative elements passing 
through the absorbents are charged with a species of energy, 
rather than a normal product of decomposition; a force that 
has the peculiar power of imparting its characteristic proper- 
ties to every bioplast with which it comes into contact. The 
lymph now does not convey a passive septic material, going 
wherever carried hx the fluid in which it floats, but an active 
poison, which propagates itself and extends its operations by 
processes vital in character, and only follows the lymph chan- 
nels because they are the most convenient for the purpose. 
We thus see one gland after another enlarged until a chain of 
them is formed, not inflamed, but enlarged from hvper-activitv. 
Occasionally, from causes not understood, the morbid principle 
or force, does not extend beyond the first gland affected, but 
becomes localized, induces active inflammation, suppurates 
and is thrown out in the discharges. This is almost uniformlv 



i 9 2 • ELEMENTS OP SURGICAL PATHOLOGY 

true in gonorrhoea and chancroid; has occasionally occurred 
in carcinoma, and with equal rarity in syphilis. The explana- 
tion may be, in a difference in kind and amount of virus. 
Thus in carcinoma and syphilis, whilst existing tissue is 
destroyed by contact with the new tissue, the morbid process 
creates; laying down of tissue is the peculiarly pathognomonic 
feature of these diseases. The tendency is both to disinte- 
grate, and to build up, albeit the new tissue is always of a heter- 
ogeneous character; still being a formative process, and vital, 
the glands assist in the act, as it were under coercion. There 
is no disintegrated tissue to expel, but tissue-forming forces to 
assist. Now it is possible, for the primary impression in 
either case, to be so profound, or acute, that the effects are 
devitalizing, and the result is more like that of non-specific 
irritation. Hence we have occasional elimination of specific 
products, even formed carcinomatous tumors. 

In the case of gonorrhoea and chancroid, as well as ery- 
sipelas and some other forms of specific disease, whilst the 
specificity is as marked as in syphilis or carcinoma, the glands 
if affected at all, present the same characters as in non-specific 
irritation. This is easily accounted for: We know that while 
the two latter diseases are characterized by the formation of 
new tissue, the former are notably destructive. In the one 
case we find only debris of the parts affected, in the discharges; 
in the other, we find little or no detritus, but new formative 
elements, representing the plastic excess. Hence the dis- 
charge from syphilitic and carcinomatous affections, is usually 
scanty; in gonorrhoea and chancroid profuse. The inference 
is easy, therefore, that the irritation is confined to one, or a 
very few glands, in the latter instances, as in the case of non- 
specific adenitis, because the conditions are similar, viz., an 
elimination of dead tissue. 

What has been gone over above, applies particularly to 
acute inflammation. When the lymphatics are the subject of 
chronic inflammation, the symptoms differ somewhat, as in the 
case of chronic inflammation in general, showing an enduring 
enlargement, both of the vessels and the glands, and a ten- 



[NPLAMMATION OF TUK I A'M l'I I ATK S 



J 93 



dency to unhealthy suppuration. The typical and familiar 
form of chronic lymphangitis is in scrofulous affections. The 
chapter on Inflammation has already given a reasonably 
graphic account of chronic inflammation in general, so much 
so that the same principles applied in the present instances will 
render unnecessary a minute account of chronic angieoleucitis. 

The Treatment is to be based upon the cause and nature 
of the inflammation, with some reference to location. Thus 
in traumatic or non-specific inflammation, w r e are to attempt a 
speedy cure without suppuration. In specific conditions, on 
the contrary, suppuration is the most desirable termination. In 
chronic cases, again, suppuration must be avoided if possible, 
yet if it is inevitable, an early discharge of the pus must be 
secured, and the process held within as narrow bounds as pos- 
sible. The treatment in specific cases will be given under the 
appropriate heading, being entirely subordinate to the general 
condition. In acute, and even chronic cases, it will rarely 
occur that there will be any necessity for other than medicinal 
treatment, unless suppuration occurs. In such an event, early 
evacuation is the proper practice, bearing in mind that there 
are occasions where the indications vary as to the propriety of 
promoting or aborting the formation of an abscess. 

Aconite is a remedy of the first importance in acute trau- 
matic cases, if non-specific. The paucity of symptoms ren- 
ders the fact of its being acute the only leading indication. 

Arsenicum takes the first rank in septic cases, where the 
characteristic symptoms, as thirst for small quantities, restless- 
ness, and internal heat are present. The skin is oedematous, 
but dry and parchment-like. 

Baryta carb. is indicated when the glands are prominently 
involved in chronic cases; there is little tendency to suppura- 
tion, the gland remains hard, though painless, for a long time, 
and if pus forms, it is in small quantities and slowly produced; 
pus is prone to become cretaceous. There is little if any 
inflammation from first to last. 

Belladonna is indicated in acute cases, of a high grade of 
inflammation; glands much swollen, red and inflamed, with 

O 



I9 4 ELEMENTS OF SCTRGICAL PATHOLOGY 

throbbing pain, pus forming of a thick yellow character. The 
lymphatics can be traced by bright scarlet lines; some puffi- 
ness of the part, but scarcely amounting to an oedema. 

Calcarea curb, is an invaluable remedy in chronic cases, in 
scrofulous subjects particularly, with glandular enlargements 
increasing very slowly, suppurating slowly, and especially 
when the cold, damp feet, sweating of the head during sleep, 
and other well-known symptoms are present. 

China has been useful in some cases, with a bare suspicion 
of septicaemia, occurring in those who have been exhausted 
by long confinement, or sustained great loss of blood. The 
symptoms closely resemble Calcarea, but are not indicative of 
deep-seated dyscrasia, as is the case with that remedy. 

Carbo veg. has followed well after Arsenic, or has been 
useful when that remedy fails, when the exhaustion is extreme, 
demanding fanning to keep up respiration. . The respiration is 
sighing, there is intense burning in the interior of the part, but 
not so diffused as is described under Arsenic; more circum- 
scribed, "as if from a live coal." 

Dulcamara has been spoken of as useful in acute attacks 
from wetting, particularly if the glands are painfully swollen, 
and the attacks are subsequently renewed whenever the patient 
gets wet, or the weather becomes rainy or damp. 

Hefar is an invaluable remedy when there is a strong dis- 
position to suppuration, and it is desirable to hasten the pro- 
cess. Given in frequently repeated doses, it will shortly induce 
pointing, and hasten the formation of the abscess painlessly. 

Lachesis is a potent remedy in septic cases in which there is 
great prostration, mental and physical; there is usually a 
marked pyaemic tendency. There is none of the restlessness 
or heat of Arsenic, apathy and lowered temperature being the 
prevailing characteristics. 

Mercurius {yivus} has long enjoyed a well-founded repu- 
tation for aborting glandular abscess in Adenitis, both acute 
and chronic. For this reason it must be very carefully used, 
as it is so closely indicated in venereal diseases that we may 
do harm by arresting suppuration when every care should be 



HYPERTROPHY OF LYMPHATIC GLANDS 195 

taken to promote it, The septic indications for this remedy 
are extreme weakness, with tendency to sweat at any motion, 
or on very slight provocation. 

Rhus tox. is the chief remedy where typhoid symptoms 
appear, with tendency to erysipelas; it has done good, service 
in pyaemia, under these circumstance, being chiefly indicated 
when there is great bodily restlessness, not so much from nerv- 
ousness, as because motion relieves what pain there may be. 

Sulphur is similarly indicated, particularly in strumous cases, 
especially if the part is erythematous, and in spite of the heat 
cold washing cannot be borne. 

Hypertrophy of the Lymphatic Glands needs little mention 
in addition to what will be said under Tumors. It is due, 
when not specific, to a chronic inflammation of the gland, 
and plastic organization. In cases of specific enlargement 
there is more than a simple hypertrophy, the new tissue, 
always heterologous, ultimately taking the place of the natural 
tissue of the part. A peculiar feature of the non-specific 
forms, as I have observed it, is that in proportion as the 
gland increases in size, its functional activity correspondingly 
diminishes. The primary enlargement, when the case is 
yet acute, induces, and in fact is due to increased functional 
activity; but in proportion as the effusion becomes organized, 
and the enlargement becomes permanent, functional life 
becomes less and less, and may cease entirely. 

Treatment. — There may be instances, in which the growth 
of the gland is immense, and if life is not endangered impor- 
tant parts are compressed by it, when excision would be 
allowable; but none such have occurred in my practice. In 
very few cases will our remedies fail, if given in strict accord- 
ance with the indications. Iodine, which some still employ, 
will not cure, as the gland may be destroyed by atrophy, if 
any impression is made. A cure can only be claimed when 
the structural and functional integrity is restored; a simple 
subsidence of the swelling, with no restoration of function, 
can only, at the best, be considered a negative success. 

Of course what has been said applies entirely to hyper- 

o 2 



IQ 6 ELEMENTS OF SURGICAL PATHOLOGY 

trophy non-specific in character. In specific cases the destruc- 
tion of the gland by suppuration is the first indication; failing 
in this, extirpation may be admissible if there is reasonable 
certainty that the morbid action is localized. Whilst we have 
many well-authenticated instances of a cure with remedies 
of hypertrophy from specific infection yet they seem to be 
rather the exception than the rule; in view of the great inter- 
ests often at stake, and the difficulty of securing clinical experi- 
ment, it must be very long ere we can hope to consider the 
condition perfectly amenable to the internal administration of 
remedies. 

Silicea, Baryta c, Calc. c, and Merc. viv. are the remedies 
oftener indicated, and their administration must be upon 
purely general symptomatic indications, not necessary to trans- 
fer from the Materia Medica at this place. 

Lymphangiectasis and Lymphoragiar-^Occasionally from 
trauma, or acquired from other causes, but more frequently 
existing congenitally, cases are seen in which the lymphatics 
are enlarged, chiefly in the form of pouches, somewhat like 
varix, the contents being thrown out in jets, in some instances, 
and in others trickling out more or less constantly. This con- 
dition is called lymphoragia, and while distinguished by these 
peculiar and pathognomonic symptoms, represents the first 
stage cf a much more serious mater, viz., a dense varicosed 
condition of the vessels, forming sometimes immense tumor- 
like enlargement of the part, known as lymfhangiectasis. 
What might well be considered two distinct forms of morbid 
action, if a specimen of each were seen in a different individual, 
represent simply an early and a late stage of the same condi- 
tion, to be considered under one head. Inasmuch as I have 
seen but two cases, I shall be forced to borrow my descrip- 
tion from another. Dr. D. C. Busey (Holmes' Surg., Amer. 
Ed., Vol. ii, p. 473), in an elaborate article on this topic, gives 
a number of cases, one of which I quote to illustrate the 
vesicular, as well the hypertrophic, or tumor form: "F. N., 
aged 19 years. When one year old the right thigh was 
larger than the left, more or less so according to the use of 



LYMPHANGIECTASIS AND LYMPHORAGLA 197 

the limb. When lour years of age, after a short walk, with- 
out unusual exertion, the right thigh was observed to be 
double the size oi the left. The swelling extended from the 
groin to the knee, was not sensitive or painful, and was 
covered with normal colored skin. It remained, now larger, 
now smaller, but occasioned no ineonvenience. After a time 
the skin upon the anterior and inner aspect, and toward the 
scrotum thinned in several places, forming small shining- 
spots slightly elevated, which ruptured spontaneously and dis- 
charged a yellowish-white, opalescent, somewhat tenacious 
fluid, which, upon exposure to air, coagulated into a jelly-like 
mass. When the rupture occurred while walking, the fluid 
would jet out for several feet, and sometimes a pint or more 
was lost, which would be followed by a sense of great exhaus- 
tion, paleness, and languor. These discharges occurred three 
or five times during a year, and continued for thirteen } T ears, 
during which time the swelling extended to the leg and foot 
and similarly thinned spots formed upon the plantar surface 
and between the toes, but none appeared upon the leg. 
When ten years old, without discoverable cause, violent pains 
around the right trochanter, extending across the right gluteal 
region and down the thigh and leg supervened. At the same 
time the extremity from the groin to the sole of the foot began 
to enlarge more rapidly, the thigh attained the circumference 
of the body of an adult, and the foot and leg increased in 
proportion. Subsequently a large abscess formed in the 
gluteal region, which after a time ruptured and discharged 
during several months large quantities of pus, and after it 
healed the thinned spots developed into transparent vesicles 
the size of peas, containing a clear liquid; the integument 
thickened and felt firmer, the epidermis roughened, the furrow r s 
deepened, and the papillae enlarged. The limb enlarged 
throughout its whole length, and numerous vesicles formed 
upon the anterior surface of the thigh, and upwards towards 
the groin and scrotum, reaching one and a half lines in height, 
transparent, and filled with watery fluid. The contained fluid 
could be pressed back, but immediately returned upon the 



Ip8 ELEMENTS OF SURGICAL PATHOLOGY 

removal of the pressure. One of the larger cysts was opened, 
and the evacuated fluid proved, on microscopic examination, 
to be lymph. Fnally pleuritis set in and the patient died. 

"Autopsy: — Skin hypertrophic throughout all its layers; 
more so upon the anterior and inner part of the femur. 
Throughout the hypertrophied portion was a large meshy net 
of dilated lymph-vessels; some of which had attained the size 
of goose-quills. The most superficial vessels could be traced 
into the cysts projecting from the skin, and they were ampulla- 
like dilatations of the extreme ends of these vessels, with thin- 
ning of their walls. Upon the lymphatic trunks situated out- 
side of this extremity, nothing abnormal could be discovered. 
The lumbar muscles were atrophied. The connective-tissue 
of the lowest portion of the leg was infiltrated with pus, the 
articular cartilage of the lower end of the tibia was destroyed, 
the ends of the bones carious, the ligaments destroyed, tarsal 
bones carious. Tubercular deposits in both lungs, beginning 
to soften; small caverns in left lung; tubercular deposits in 
liver, spleen, and other abdominal organs." 

One of the cases I saw, was in the practice of Dr. Foster, 
of Detroit, Mich., who called me in consultation only a short 
time before death. No history could be obtained, but the 
objective symptoms at that time, were very like elephantiasis. 
The right extremity throughout its whole extent, the left as 
far as the knee, the scrotum, and the whole of the abdomen 
were enormously swollen; dark color, a reddish brown — and 
very hard. On deep pressure with the finger, however, there 
was pitting, slowly filling up, and as this excluded elephantiasis, 
1 was not able, at that time, to make a diagnosis. At the 
autopsy, assisted by Drs. Olin and McLaren, the integu- 
ment was found enormously hypertrophied, as described above, 
large quantities of lymph flowing out of the incisions. The 
abdomen was filled with chyle {ascites chylosus), and the 
appearances were precisely as given in the case quoted from 
Dr. Busey. 

The cases quoted give a sufficiently accurate account of the 
semeiology, and nothing need be added. There is much varia- 



[NJURIES OF THE LYMPHATICS 199 

lion in the symptoms in different cases as far as external 
expression is concerned: in some there is thickening of the 
skin: in others not; in some there is a distinct varicose con- 
dition of the vessels, sometimes associated with a similar con- 
dition of the veins, in which event the diagnosis is very 
obscure. In all, however, there are certain symptoms that 
may be said to be pathognomonic, particularly the weakness 
and debility, far beyond what would be present in simple varix 
of the veins. 

The causes are not, I may say, understood. Nearly all 
writers, even in the most carefully written and elaborate works, 
are content to refer it to an occlusion of the vessels, perhaps 
occurring accidentally, in some cases congenital. They seem 
to forget, that, as will be shown shortly, these vessels are fre- 
quentlv divided, or injured in connection with injuries to the 
tissues in which they are found, and such results as have been 
described are exceedingly rare. That there is a hypertrophic 
diathesis — if the word is admissible — is very evident; whence 
it arises, it is, at present, impossible to divine. Very unwill- 
ingly I am compelled to decline to argue this question further, 
as after patient study I am utterly unable to form any theory 
of causation that seems reasonable. One case in my experi- 
ence was due to stricture of the thoracic duct, from extension 
of scirrhus of the pancreas. 

As little can be said of Treatment. I am not aware that a 
case has ever been cured, b} T any means, local or general; 
strapping, compression with collodion, astringents, and the 
whole armory of old-school practice have been employed, and 
all alike have failed. In our own literature I cannot find a 
single case, and considering the pathological anatomy I do not 
see how anything can be done, particularly when the condition 
is well advanced. 

Injuries of the Lymphatics. — The lymphatics are neces- 
sarily wounded very frequently, and rarely, if ever, attract any 
attention as far as results are concerned. In fact I am not 
aware that they enter into the calculations in planning opera- 
tions in the exterior of the body, unless it be in the supra- 



200 ELEMENTS OF SURGICAL PATHOLOGY 

clavicular fossa on the left side, where a deep dissection might 
endanger the thoracic duct. They seem to heal with unusual 
readiness, or if they become occluded no ill-effects have been 
observed. In very exceptional cases, however, hardly enough 
in number to warrant consideration, fistula? have formed 
through which there is a slight exudation of lymph. I am not 
aware that mere traumatism, apart from any constitutional or 
congenital defect, has ever induced a serious disease of the 
lymphatics. 



XIV— PATHOLOGY OF THE BLOOD-VESSELS 

The blood-vessels, arteries, veins, and capillaries, exhibit 
changes in structure that not only indicate local and accidental 
occurrences, but are frequently expressions of widely distrib- 
uted morbid action. The consequences, depending upon 
extent and kind of degeneration, may be entirely local, or 
threaten life. It is doubtless true that many cases of serious 
and profound alteration in the structure of blood-vessels can- 
not be recognized during life, and the mere therapeutist might 
rind little of interest in the discussion, were it not for the fact, 
that many recognizable phases of morbid action give timely 
notice of threatened danger. Thus in spontaneous aneurism, 
it is to be inferred that some degenerative change in the blood- 
vessels has commenced, and its further extension may be pre- 
vented. So in calcification of vessels, it might serve a useful 
purpose to know that rupture of a cerebral vessel was among 
the possibilities of the future. In an elementary work like the 
present, it is impossible, and even undesirable to exhaust the 
subjects thus opened up; the principal abnormalities will alone 
be discussed. 

We find that the commoner changes in the vessels are 
chiefly trophic, it is true, but in many cases there is some con- 
structive or degenerative morbid action; there may be also a 
metaplastic process operative, which, however, does not ca.l 
for extended or separate consideration, as the consequences 
and general characters are those of hypertrophy. These 
questions can be more intelligently presented, if a distinction is 
made between the arteries and the veins, for although many 
of the forms of morbid action are common to both, yet the 
consequences are very different. 



202 ELEMENTS OF SURGICAL PATHOLOGY 

ATROPHY OF BLOOD-VESSELS. 

Atrophy of blood-vessels, by which is meant a diminution 
in the vessel, in every way, lessened calibre, and attenuated 
walls — is sometimes observed as a concomitant of general 
marasmus. More frequently it is due to local influences, trau- 
matic in character, such as would have the effect to cut off 
circulation in certain territories. Typical instances of atrophy 
are observed after amputations, or operations that divide 
arteries, the collateral circulation having the effect to so change 
the distribution of blood in the part, that certain vessels lose 
their importance. Such cases, however, are not at all path- 
ological; pure atrophy is such as would accompany or be 
responsible for symptomatic ischaemia. There are cases in 
which a thinning by absorption of one or more of the coats of 
a vessel occurs, either from inflammation, or pressure from 
contiguous morbid growths, or hypertrophied parts, even an 
over-stretching from rapidly established swelling. There are 
others in which the vessels of a part partake in a morbid 
action, such as diphtheria, tuberculosis and the like, and un- 
dergo necrosis, or even a more subtle form of disorganiza- 
tion, necrobiosis. In most of these varieties of atrophy, the 
amount of blood passing through a vessel is proportionately 
diminished, so that nothing follows beyond loss of blood to the 
tissues normally supplied. Where there is compensating col- 
lateral circulation, there is little if any loss, and no tissue 
changes are observable; where this is not the case, ulceration 
or gangrene is a natural result. In cases where there is 
atrophy of the coats, one or all, without diminished blood- 
volume or narrowing of the lumen, aneurism, or rupture is to 
be feared. 

HYPERTROPHY OF BLOOD-VESSELS. 

Hypertrophy is perhaps more common than atrophy, and 
to some extent has a closer relation to pathology. There is 
an augmented calibre, and increased thickness of the walls, 
very frequently with increased length as well, shown by the 
convoluted form into which it is thrown. Increased tension, as 



AWTEUITIS 



203 



occurs in Blight's disease, is the exciting cause for hyper- 
trophy, but it may exist, in a somewhat modified form, as a 
result of a mild attack of inflammation, with plastic exudation. 
The anastomotic aneurism is an illustration of hypertrophy. 
The conditions giving rise to the increase of tension are gen- 
erally some interruption in the circulation, as a ligature, or 
compression of a vessel from a tumor, or the like; in the lat- 
ter case it is not unusual to find the distal part of a hyper- 
trophic^! vessel atrophied, the same cause, an obstructed cir- 
culation, giving rise to the two conditions. 

ARTERITIS. 

Inflammation of an artery will nearly always be responsible 
for the morbid changes with which we have to do. Arteritis 
is a term used to describe an inflammation of the whole sub- 
stance of the arterial coats; when the internal coat (intima) is 
alone involved, it is called endarteritis ; that of the middle coat 
[media) mesarteritis; when the external coat (adventitia) is 
invaded, it is called per i-arter it is. From the fact that certain 
results follow inflammation of one or the other tunics, as 
well as that post-mortem examination shows such to be the 
case— we know that inflammation may be confined to one of 
the tunics, or at least originate therein, and pass to others, or 
involve the whole structure secondarily. In practice it is pos- 
sible, sometimes easy, to diagnosticate an arteritis, but unfortu- 
nately it is not always possible to determine in which tunic the 
inflammation originates, and thereby have early information 
of threatened danger. 

As to causation arteritis may arise from traumatism, in 
which case it is not an uncomplicated lesion; or it may be 
symptomatic, partaking in an inflammation of parts with which 
the artery has close relation; or it may be idiopathic, arising 
from causes within itself, or some determining factor within 
the blood. 

The results are directly related to the cause. Thus in 
traumatic cases, resolution must be the rule, and unless there 
is some actual injury to the vessel, such as a laceration or 



204 



ELEMENTS OF SURGICAL PATHOLOGY 



severe contusion — function should be restored. In symp- 
tomatic cases, much depends upon the character of the asso- 
ciated malady, whether specific or otherwise. The same 
remarks apply to the idiopathic class, but from the nature of 
the causation there is much greater liability to permanent 
injury to the vessel. The general characters of an arteritis 
are as follows: The occurrence of inflammation, it will be 
remembered, establishes a certain group of symptoms, swell- 
ing being one of the most prominent. It matters not in which 
tunic the process commences, the extension must be away 
from the most resisting tissue, and be greatest in the most 
vascular, or that of the loosest texture. It matters little, 
therefore, which of the arterial coats originates the inflamma- 
tion, the inner and middle must be more swollen than the 
outer, with the result that the lumen of the vessel is corre- 
spondingly encroached upon, and the passage of the blood 
impeded. In extreme cases the lumen may be entirely closed, 
the circulation completely arrested, and the vessel destroyed. 
Should the vessel be a large one, the parts it supplies may 
undergo mortification, unless collateral circulation is quickly 
established; if one of lesser magnitude, ulceration is to be 
feared. 

The terminations of the inflammation are as in other tissues; 
hence suppuration may occur, or the vessel perforated by 
ulceration; in severe cases the more common termination is 
permanent occlusion, with atrophy below and hypertrophy 
above the focus, the atrophy proceeding to conversion of that 
portion of the vessel into a fibrous cord, as occurs after liga- 
ture. When perforation ensues, it may be confined to one or 
two coats resulting in aneurysm, or extend through them all, and 
set up a haematoma ox false aneurysm. In other cases, as will 
be shown later, some degenerative process may be established, 
as calcification, sclerosis, and fatty degeneration. There is 
still another consequence, and one of quite frequent occurence, 
viz., embolism. The lesion to the intima, the narrowed lumen, 
and the retarded circulation, furnish all the conditions for 
coagulation, or thrombosis. A clot may form, become detached, 



TREATMENT OF ARTERITIS 205 

or portions of it. carried along for a distance and lodge, plug- 
ging up the vessel, and thus set up what is called embolism. 
The consequences now depend upon the location, as a matter 
of course, and do not concern us at present. 

The Symptoms are not obscure when the vessel is super- 
ficial. The first indication, usually, is a sudden pain, obscure 
in character, and diffused. It rapidly increases in intensity 
and becomes localized in the course of the vessel; the extrem- 
ity becomes more or less swollen, hot and red; if an extremity 
is the seat, it is ilexed, the sufferings being increased when it 
is straightened. The pulse below the focus of inflammation 
is wiry and hard, above full and strong; the vessel is very 
sensitive to touch and pressure. Later, the pulse is weak, 
perhaps quite imperceptible, the temperature is lowered, and 
the color changed. If collateral circulation is established these 
symptoms gradually improve; if not they may pass over into 
those of gangrene. There is usually considerable oedema, 
particularly on the distal side. Should embolism occur, it will 
be announced by a sudden pain, " like an electric shock," 
with rigor, and cessation of pulsation below the point of lodg- 
ment. The distinguishing features are pathognomonic: The 
pain in the course of the vessel, the alterations in pulsation, 
and the swelling or oedema of the part evidently not due to 
inflammation of the tissues. 

The Treatment of arteritis, without any of the complica- 
tions noted above, is quite simple. In the early stages Aconite 
is alone indicated, as a rule; later Belladonna is the most prom- 
inent remedy. Other remedies may be needed, but the 
symptoms are so unvarying, that the number is very few. 
They will be those already mentioned under Inflammation. 
As adjuvants warm applications, and an easy position for the 
part are all that seem called for, unless embolism occurs. In 
this case, if the embolism is at the seat of inflammation, it has 
been advised to attempt breaking it up, by massage. There 
are objections to this practice, one of them being the aggra- 
vation of the existing inflammation; the other the dispersion 
of the clot threatening distant embolism, perhaps multiple, 



206 ELEMENTS OF SURGICAL PATHOLOGY 

and in less desirable localities. Should the vessel be an 
important one, and collateral circulation not promptly secured, 
breaking up the thrombus may be imperatively demanded, 
in spite of the risks thereby incurred The prominent indica- 
tion, however, is to establish collateral circulation as soon as 
possible. In dispersed or distant embolism, if the spot can be 
reached, massage is a good practice, as the clot being broken 
into small pieces, if lodgment does occur at a distance, it will 
be in smaller, and presumbly less important vessels. Where 
massage is impossible, Arnica must be given, in the hope 
that the clot will be absorbed, although too much must not be 
expected. Secale has been used with success, on purely 
experimental indications, but Arnica seems to be the most 
reliable agent. 

PHLEBITIS. 

Phlebitis is an inflammation of the veins, like arteritis being 
traumatic, symptomatic, or idiopathic. The symptoms, as a 
rule, are not so urgent, as in arteritis, but the consequences 
are frequently exceedingly grave. When deep vessels, of 
some magnitude are inflamed, the symptoms are very similar 
to those of arteritis, with the exception of the changes in the 
pulse; there is more oedema, and less heat of the part. In 
the case of superficial veins, the diagnosis is comparatively 
easy. The veins are swollen, hard, hot, painful, and oedema 
is marked. The books give a large number of varities of 
the disease, classified with reference to extent, tissues affected, 
natural history, and terminations; as a matter of fact the whole 
question may be considered under three heads, relating entirely 
to complications and terminations: Ephemeral, adhesive, and 
suppurative. 

Ephemeral Phlebitis would represent the milder types, in 
which resolution occurs leaving the parts as they were before 
the attack, perhaps with some thickening of the coats of the 
vessel, but nothing notable in the way of lost or modified 
function. 

Adhesive Phlebitis represents an inflammation of a higher 



DEGENERATION OF BLOOD-VESSELS 207 

grade of intensity, in which there is plastic exudate sufficient 
to obliterate the vessel by adhesion of opposing surfaces of the 
inner coat. This, of course, obliterates the vein, but the con- 
sequences are rarely serious, as collateral circulation is readily 
established. 

Suppurative Phlebitis is where the process terminates in 
suppuratton, the pus being in the vessel, or external to it, in 
the sheath. As a rule the suppurative form is developed 
from the adhesive, so that the order of intensity or gravity, 
would be in the order here given. It will serve a good pur- 
pose to consider a bad case as passing through these three 
stages, although a given case may develope only through one 
or two of them. In the ephemeral form, as already said, the 
vessel may be left as the inflammation found it, slightly thicker 
walls perhaps, but the blood may and frequently does undergo 
the most important changes. Thrombus is formed, either 
occluding the vessel completly, and leading to the adhesive or 
suppurative forms, or else breaking up, and distributing its 
fragments throughout the body, probably resulting in embo- 
lism in various places, chiefly in the liver or lungs. If the 
case goes on to suppuration, pyaemia is almost a certainty, 
whether the pus be extra- or intra-vascular. 

The Treatment is necessarily to be determined by the 
kind or grade of inflammation. In the simpler ephemeral 
forms Aconite will be needed. In the more severe types, in 
which obliteration of the vein seems threatened, and yet there 
are no signs of suppuration, Rhus tow is prominently indi- 
cated. When suppuration is evident, Arsenic or Lachcsis will 
be called for. There are cases in which JSfux vomica or Ham- 
mamelis will be useful. The former when the course of the 
case is sub-acute or chronic, the vein being thickened and 
firm; the latter when the vein feels thinned, and dilated, 
• ; pouch-like." 

DEGENERATION OF BLOOD-VESSELS. 

Usually as a result of inflammation, but in exceptional 
instances from unknown causes, the tunics of blood-vessels 



20S ELEMENTS OF SURGICAL PATHOLOGY 

undergo degenerative changes. Probably in the majority of 
cases the first step is a deposit, which fails to organize in a 
normal manner. The more frequent of these degenerative 
processes are given below, not so much from any therapeutic 
interest, as from the fact that they are many of them forerun- 
ners of one of the most serious accidents that can befall a 
human being: viz.. aneurysm, 

Fatty Degeneration is oftener found in the inner and mid- 
dle coats, rarely extending to the adventitia. following a chronic 
inflammation. It commences in a fatty degeneration of the 
cells, which become rilled with oil-globules; at first the depos- 
its are between the muscular or elastic fibres, gradually pene- 
trating the sarcolemma. until later the proper tissue has 
disappeared, and masses of fat occupv its place. In the earlv 
stages the changes are not apparent to the naked eye. but later 
the tissue is seen of a vellowish color, and is found to have lost 
its elasticity or resiliency. The effect that such a change in 
the tissues must have on the circulation and nutrition can be 
readily conceived, and needs no lengthy mention at this time. 
The vessel not only loses its elasticity, and consequently a con- 
siderable factor in the circulation is lost, but it becomes brittle. 
and exposed to laceration or rupture in suddenly increased 
tension. The danger to life is not inconsiderable, therefore, but 
practically other consequences are more prominent. 

Calcification of the vessels is one of the chief results. 
indeed it may be said to be the second step in a series of 
changes of which fatty degeneration is the first. There is a 
partial absorption of the fluid portions of the fat. that which 
remains having more the appearance of cholesterine. at least it 
is dry. of a whitish color, and compact. Granules of carbon- 
ate of lime now appear, scattered about between the fibres, 
gradually forming masses, and tending to an organization into 
plates or laminae, so that in some cases the whole of the media, 
for considerable distances., will be converted into a calcareous 
mass, with none of its organic characters remaining. In some 
cases this degree of organization is not attained, the media 
being densely infiltrated, but not disposed in plates or laminae. 



DEGENERATION o\' BLOOD VESSELS 



209 



The same degeneration of the aged, prematurely or naturally — 
often occurs, without, so far as has been observed, an anteced- 
ent fatty disorganization ; in such cases the laminated arrange- 
ment seems to be the rule. I have seen one case, in which I 
amputated the thigh for gangrene ot the leg, where the fem- 
oral artery was a mass of calcareous matter, but not notably 



laminar in arrangement. 



Atheroma is a substance of a "pappy" character, found 
chiefly in connection with the intima, that Ziegler {Path,, p. 
427) tell us is "essentially a necrosis with granular and fatty 
disintegration of the intima." It may, therefore, appear de 
novo, in either the media or intima, or be a later phase in fatty 
degeneration; it is also a frequent antecedent to calcification. 
It is in most cases the result of inflammation, the vaso vassorum 
being obliterated, and the nutrition of the vessel thereby 
reduced. Once formed, it has a disposition to set up ulcerative 
action, which brings about results yet to be considered. It 
may occupy a small territory, or be widely diffused throughout 
the vascular system. 

Considering these three forms of degeneration to be, as they 
undoubtedly are, different phases of one and the same thing, 
namely fatty-metamorphosis, an explanation for the abnormal- 
ity is lucidly given by Ziegler (/. c.) as follows: "52. The 
cause of fatty degeneration is to be sought in an alteration in 
the constitution of the blood, i. e., of the nutriment supplied to 
the cells. Deficient supply of oxygen plays a chief part in it. 
To this must be ascribed, on the one hand, the disintegration 
of albumen and the formation of fat; on the other hand, the 
fact that the fat produced is not straightway consumed. If to 
the lack of oxygen there is added a deficiency of proper nutri- 
ment, so that the albumen which is used by transformation into 
fat, is not replaced, the amount of albumen in the affected part 
must of course diminish. Corresponding to the case just indi- 
cated, w r e find fatty degeneration taking place in conditions 
which are associated with general or local anaemia. For 
example, if the blood becomes diseased in such a way (anaemia, 
leuckoemia) that its power of taking up oxygen is diminished, 

P 



2io ELEMENTS OF SURGICAL PATHOLOGY 

and its nutritive value lowered, fatty degeneration is found to 
occur in the most widely different organs. The same thing 
comes to pass in particular organs which happen to receive too 
little blood, either in consequence of disease in the afferent 
vessels, or because the outflow of blood from them is checked 
or its renewal hindered. Lastly, organs like the muscles, 
which for any reason are left unexercised, and so fail to undergo 
an adequate amount of tissue-change, are very apt to become 
fatty." 

A question of interest at this point, might be somewhat 
enlarged upon. Many of these degenerations are accompani- 
ments of senility, but senility is sometimes acquired and pre- 
mature. Certain habits, particularly addiction to alcohol, 
precipitate these conditions, and we thus find aneurysm, and 
vascular lesions dependent upon such degenerations, com- 
moner among those races in which such habits prevail, as the 
Irish'', and less so among such people as the Arabs. Spontane- 
ous aneurysm will therefore always give rise to the suspicion 
that the vascular system is abnormal, and thus lead to more 
enlightened therapeutic measures. 



XV— PATHOLOGY OF THE NERVES 

The pathology of the nervous system is a subject of SLich 
enormous magnitude, that it would be utterly impossible to 
give 5 in a single chapter, anything even in a summarized form, 
that would answer any useful purpose, practically or theoreti- 
cally, that at the same time attempted to cover the ground. 
Brain and cord surgery are not only subjects to which a large 
volume could be profitably devoted, but are at the same time 
of an eminently special character. After many changes of 
purpose, it has been thought best to attempt nothing more than 
a brief resume of pathological facts connected with conditions 
that are oftener presented to the general surgical practitioner, 
with particular reference to their significance as prodroma of 
graver neuroses. From this point of view all lesions of nerves 
may be considered as initial conditions of paralysis or paresis, 
and can be included under a few heads, as irritative, inflamma- 
tory, or degenerative, one leading into the other, in the order 
of statement. 

NEURALGIA. 

Neuralgia is an irritation of sensory or motor nerves, giving 
rise in one case to pain, and the other to reflex phenomena of 
various kinds. The attacks are usually remittent or intermit- 
tent, coming on at irregular intervals, as a rule, although, at 
times they are periodical, associated with some habitual func- 
tional disturbance, as menstruation. The pains are of all kinds 
and description, having a single characteristic to distinguish 
them from pains from other causes, viz., their being localized, 
and in the course of a nerve distribution. Neuritis has the 
same characteristic, it is true, but with important differences as 

P 2 211 



212 ELEMENTS OP SURGICAL PATHOLOGY 

will be shown later. During the paroxysm, when it reaches 
its climax, there may be an extension of the irritation to the 
motor nerves, when there will be twitching of muscles, or 
some other symptom of reflex excitement. The temperature, 
local or general, is little if any affected, although fever is not 
an uncommon concomitant in severe or protracted cases. The 
attack passing off leaves the parts perfectly free from pain and 
sensitiveness, although in chronic cases they are easily re- 
excited, and the parts remain more or less sensitive to pres- 
sure. In such cases, however, it is often more than a mere 
neuralgia. 

The Causes of neuralgia are essentially innutrition, either 
anaemia or hyperaemia, in all cases, probably, some deficiency 
in blood-supply will be the controlling factor. The exciting 
causes are anything which may act as an irritant; local injury, 
exposure to heat, cold, or wet; over-study, or too close appli- 
cation to business; mental emotions of various kind; fatigue, 
or indiscretions in eating and drinking. Etiologically these 
factors are of very secondary value, but in therapeutics they are 
of the first importance as indices to remedies. It is possible 
for a single attack of neuralgia to appear without any notable 
alteration in blood-supply, from the direct application of an 
irritant, without any general derangement; in other words the 
condition may be purely local in all respects. The frequent 
repetition of the irritant, however, will have the effect to 
establish a permanent irritation in various ways. Inclusion of 
a nerve in a cicatrix, plastic adhesions to near parts, tension 
from stretching over a growing neoplasm, compression from 
similar causes, or anything, in short, that would interfere with 
the blood-supply, or expose the nerve to constant irritation. 

Frequently when a cure is not readily secured by remedies, 
it will be found that the prescriber has failed to note the fact 
that a structural lesion is responsible for the symptoms, or 
that, under other circumstances, he has directed his attention 
to the -painful point alone. It scarcely needs mention that an 
irritant at the root of a nerve does not produce symptoms at 
that point, at least primarily; the first symptoms are felt at 



TREATMENT OF NEURALGIA 213 

the distribution. In later stages the point of irritation is indi- 
cated by the localization of symptoms. In recent cases of 
neuralgia, therefore, the point of irritation must be looked for 
deeper, by tracing up the nerve to its emergence from a 
foramen, some point of division from a main trunk, or where 
a sharp turn is made. In many cases neuralgic pains at a 
distance may be set up, almost at any time, by pressure on 
such a point. The fact must never be lost sight of that a 
symptom is never purely functional, if by "functional" is 
meant absence of structural lesion. There are cases in which 
it is of the utmost importance to determine the kind of lesion, 
if for nothing else than prognostic purposes. 

The significance of neuralgia, to the surgeon, lies in the 
fact that all profound nervous diseases have their origin in a 
neuralgia which gradually passes over into a neuritis, and 
some form of degeneration, or is caused by some pathological 
process somewhere in the course of the nerve. For these 
reasons each case must be carefully studied, the source of the 
symptoms sought for, and treatment directed to the disposal 
of the irritant. Frequently the removal of a small tumor, 
callus from a repaired fracture, or freeing a nerve from cica- 
tricial implication will at once and forever cure a neuralgia 
that otherwise would have inevitably developed into a neuritis 
and atrophy, with some form of paralysis. 

Treatment. — In ninty-nine cases out of a hundred the 
indicated remedy will be found promptly curative; in the 
other case some lesion will be found to which attention must 
be directed without regard to symptomatic indications. The 
list of remedies includes pretty much all of the Materia Afed/ca, 
but the following taken from another work (Surgical Thera- 
peutics) have been those that have given me the best results. 

Aconite. — Vertigo on rising up in bed; crampy sensations 
at root of nose, making her feel as if going crazy; feeling as 
if the whole brain would press out at the forehead; she fears 
to be in a place of excitement or confusion. Insupportable 
pains, especiallv at night; shooting or pulsating pains; thirst; 
redness of the cheeks; small and quick pulse; great sensitive- 



214 ELEMENTS OF SURGICAL PATHOLOGY 

ness of the whole nervous system, especially of the organs of 
sight and hearing. Worse in the evening and at night; also 
from warmth. Better when at rest and in the open air. 

Allium cei>a. — Pains violent and continuous; chronic neu- 
ritis, which is wearing the patient out. 

Ammonium carl?. — Feeling as if the head would burst; 
anxiety, with inclination to w T eep; discharge of sharp, burn- 
ing water from the nose; pale bloated face; much thirst; 
debility, compelling one to lie down; great sensitiveness to 
cold; tearing and burning pains; pulse hard, tense and fre- 
quent; attacks of chilliness in the evening; during the day 
and in the morning, perspiration, principally about the joints. 
Worse in the evening; also from wet poultices and pressing 
the teeth together. Better from pressure and warmth. 

Anacardium. — Loss of memory; fluent coryza; loss of taste; 
diminished sensibility, particularly of smell, sight and hearing; 
sensation as if a hoop or band were around the parts; pulse 
accelerated, with beating in the veins; coldness internally, 
with external heat; clammy perspiration of palms of the 
hands. Worse in morning, periodically; also from rubbing. 
Better during dinner. Left side. 

Apis mel. — Restlessness; twitching of the eye-balls; cedem- 
atous swelling of the lids; redness and swelling of both 
ears; burning or stinging heat in the face, with purple color; 
cedematous swelling of the face; thirstlessness; tension over 
the eyes, behind the ears and in the neck; pulse full and 
rapid, or small and trembling; intermitting pulse; chilliness 
from the least movement, with heat of the face and hands; 
sharp pain like a bee-sting, Worse in the morning, evening, 
and at night; also from heat. Better from cold. Left side. 

Arnica. — Crawling, pricking in the part; agitation and 
restlessness, which compel the patient to move the parts con- 
tinually; great sensitiveness to noise; heat of face, cold body; 
hot, red, shining swelling of one cheek; burning, hot, cracked 
lips; thirst, desire for cold water; longing for alcoholic drinks; 
pulse very variable, mostly hard, full, and quick; internal 
chilliness, with external heat; perspiration smelling very 



TREATMENT OF NEURALGIA 215 

bout, sometimes cold. Worse in the morning, evening and at 
night; also on moving, being touched, and from cold. Better 

from warmth. 

Arsenicum. — Burning or tearing pains, felt even during 
i : pains become insupportable, so that he becomes furious, 
and despairing; great anguish; excessive weakness, so that he 
has to lie down; intermission of the pain, when sensation of 
coldness in the part affected; the pain is so great that the 
patient is continually moving from room to room, or place to 
place: swelling and burning of the nose; fluent coryza of 
burning, sharp, excoriating water; puffiness of the face, 
especially around the eyes; distorted features; lips black, dry 
and cracked; longing for cold water, acids, and alcoholic 
drinks; sudden sinking of strength; pulse frequent in the 
morning, slower in the evening; skin dry like parchment. 
Worse at night, and in morning; also from cold, w T hen lying on 
the affected side. Better from heat in general. 

Asaftxtida. — Hysterical restlessness and anxiety; sensation 
of numbness of the bones of face; twitching and jerking in 
muscles; pulse small, rapid, and unequal. Worse in the after- 
noon and evening. Better in the open air. Left side. 

Arum met. — Melancholy mood, dejected, inclined to weep, 
and longing to die; almost driven to suicide; fiery sparks 
before the eyes; roaring in the ears; very sensitive smell; 
bloated, shining face; immoderate thirst; hysterical spasms 
with laughing and crying alternately; pulse is small, but accel- 
erated. Worse in the morning; also from cold. Better from 
motion and warmth. 

Bartya c. — The light hurts the eyes; in the dark he sees 
spots before them; dark redness of the face; tension on the 
face as if it were covered with spider's webs; flushes of heat; 
pulse weak, but accelerated. Worse at night; also when 
thinking of it. Better in open air. 

Belladonna. — Nervous anxiety and restlessness; eyes spark- 
ling, red, and glistening; looks wild, unsteady; inflammation 
of the ear; dullness of hearing; inflammation and redness of the 
nose; sense of smell preternatural!}' acute; purple-red and 



2i6 ELEMENTS OF SURGICAL PATHOLOGY 

hot face; alternate redness and paleness of the face; spasmodic 
distortion of the mouth; violent cutting pains; the upper lip is 
swollen; excessive burning thirst; inability to swallow; pulse 
accelerated, often full, hard and tense; sometimes soft and 
small; if slow the pulse is full; dry heat with thirst; perspira- 
tion on the head, or only on those parts that are covered; the 
patient seems to be in a stunned or stupid condition. Comes 
suddenly, goes as quickly. v Worse at night; also from the 
least touch, from light, or noise. Better while lying down and 
from strong pressure. Right side. 

Bismuth nit. — Excruciating pain, relieved by pressure, and 
on moving about. 

Bryonia. — Expansive pains; exceedingly irritable, inclined 
to be angry; burning in the eyes, and edges of the eyelids; 
the eyes feel as if pressed out of the head; the upper lids are 
particularly swollen; does not drink often, but much at a time; 
swelling of the affected parts, with inability to move them; 
pulse full, hard and tense; perspiration profuse, and very 
easily excited; restless, but compelled to keep very still. 
Worse in the evening; also from motion, or sitting up in bed, 
and from heat. Better on getting warm in bed. Right side. 

Calendula off. — Provings of this remedy are very incomplete, 
but the little use I have made of it justifies me in recommend- 
ing its use, topically at all events, in neuritis resulting from a 
lacerated wound. 

Camphor a. — Great anguish and discouragement; confusion 
of ideas; aversion to light; usually thirstlessness; sometimes 
violent thirst; sudden and great sinking of strength; death-like 
paleness of the face, alternating with redness; icy-cold face, 
purple or pale; distorted countenance; foam at the mouth; 
icy-coldness of whole body, with paleness of face; pulse small, 
weak and slow; cold perspiration, often clammy, and always 
very debilitating. Worse at night; also from cold. Better 
when thinking of it. 

Cannabis ind. — Heat of the skin; copious perspiration; pulse 
very slow, with nausea; general restlessness; desire to sleep ? 
inability to do so; dry mouth and thirst. 



TREATMENT OF NEURALGIA 217 

Cantkarides. — Anxious restlessness, ending in rage; eyes 
protruding: fiery, sparkling, staring look; death-like appear- 
ance; expression of terror and despair; hot, red, and swollen 
face: thirst, but yet an aversion to all fluids; pulse hard, full, 
and rapid: burning heat, with anxiety and thirst; cold perspira- 
tion, smelling like wine. Worse in the afternoon and night; 
also from coffee. Better from lying down. Right side. 

Capsicum. — Peevish, easily offended; redness of the cheeks 
without heat, often changing to paleness; swollen and cracked 
lips: thirstlessness ; pulse irregular, and often intermitting; 
heat, with perspiration and no thirst. Worse in the evening, 
and at night; also when eating or drinking or beginning to 
exercise. Better from continued exercise. 

Carbo veg\ — Sensitiveness and irritability; burning and 
pressing in the eyes; pulsations in the ears; great paleness of 
the face, swollen face and lips; greenish color of the face; 
excessive thirst; numbness of the limbs (and parts affected); 
burning pain; pulse small, weak, imperceptible, uneven or 
intermittent pulse. Burning like a coal of tire, in a small 
spot. Worse in the morning and forenoon; also in the open 
air, from poultices and pressure. ■ Better after lying down. 

Causticum. — Melancholy, peevish, low-spirited; buzzing and 
roaring in the ears and head; painful swelling of the external 
ear; yellowness of the face, especially the temples; spasmodic 
sensation in the lips; sensation of tightness and pain in the 
jaws, making it very difficult to open the mouth or to eat; 
violent thirst for cold drinks; pulse only accelerated towards 
evening; flushes of heat; sensation of internal chilliness; fol- 
lowed by perspiration without previous heat; perspiration is 
sour. Worse in the evening; also in the open air. Better 
from heat. 

Cedron. — Unvarying periodicity to the hour. 

Chamomilla. — Ill-humor, taciturn; aversion to a bright 
light; sensitive hearing and smell; bloatedness of the face; 
swelling, with hardness and blueness of one cheek; heat of 
the face while the rest of the bod)* is cool; great thirst, with 
longing for cold water; great prostrating debility as soon as 



2i8 ELEMENTS OF SURGICAL PATHOLOGY 

the pain begins; pulse small, tense, and accelerated; heat, 
with occasional chills; heat, with anxiety, and perspiration of 
the face and scalp. Wild and unruly; wants relief at once, 
hot sweat, from pain. Worse at night; also while lying down, 
and during sweat. Better while fasting, and on rising. Left 
side. 

China off. — Indifference and apathy; humming in the ears; 
heat and redness of the nose; violent thirst for cold water; 
drinks often, but very little at a time; face pale and sunken; 
red and bloated face; the lips are swollen; pulse small, hard, 
and rapid, or irregular; over-sensitiveness of the nerves from 
loss of fluids. Pale and prostrated after attack. Worse at 
night; also from the slightest touch, after drinking. Better 
in the room, and from strong pressure. 

Cicuta vir. — Hardness of hearing; deadly paleness of the 
face, with coldness of the face and hands; red. face; grinding 
of the teeth; the throat feels closed; inability to swallow; 
violent thirst; spasms of the muscles, especially of the neck 
and chest; pulse weak, slow 7 , and trembling; internal heat. 
Worse in the afternoon; also from cold. Better when in bed, 
and from warmth. 

Cimicifuga. — Severe pain in the left jaw; heat on one side 
of face, with lassitude all over; very severe pain in the face, 
more in under jaw, lower teeth, and articulation of lower jaw; 
pains in head and face constant, and very severe; pain in 
right superior maxillary bone and teeth. 

Cina. — Disposition to be offended by trifling jests; bloated, 
pale face, with blueness around the mouth; pale, cold face, 
with cold perspiration; increased thirst; the body is stretched 
out, and becomes rigid; dull stitches in different parts of the 
body; the limbs twitch, and are distorted; pulse small, hard, 
and rapid. Worse at night; also from external pressure. 
Better after lying down. Left side. 

Cocculus. — Pain in the eyes, as if they were torn out of the 
head; hardness of hearing, with noise as of rushing water; 
heat in the face, and redness of the cheeks; sensation of 
extreme weakness; disposition to tremble; trembling of all 



TREATMENT OF NEURALGIA 



219 



the limbs: pulse small and spasmodic, sometimes it cannot be 
felt; perspiration of the parts affected. Worse in the evening; 
also from talking, sleeping, drinking, and in the cold air. 
Better from pressure and warmth. 

Cojf'ea. — Over-sensitiveness; weeping mood; sense of hear- 
ing more acute; dry heat in the face, with red cheeks; nightly 
thirst; the pains are intense, driving to despair; twitching 
of the limbs; chilliness increased by every movement; head 
feels contracted and too small. Slight pain unendurable; 
hysterical. Worse at night; also from the open air. Better 
from cold water in the mouth. 

Colocynth. — Aversion to talk; disinclined to answer ques- 
tions: pulsation and rushing in the ears; fluent coryza; face 
pale and relaxed, with sunken eyes; dark redness of the face; 
tearing, or burning, or stinging pain on the left side, extend- 
ing to the ear and head, swelling of the face, with redness 
and heat of one cheek; twitching of the muscles; faintness 
with coldness of the extremities; burning pains; pulse full, 
hard and accelerated; internal heat; attacks of flushes of 
heat. Cutting, lancinating pain. Worse in afternoon and 
evening; also when lying down, and lying on painless side, 
or making least motion. Better when lying on painless side, 
and from motion. 

Conium 1112c. — Inclination to start as if with fright; great 
and painful sensitiveness of hearing; roaring and humming in 
both ears; excessively acute smell; heat in the face stinging- 
tearing faceache; dry and scaly lips; sensation of debility; 
sudden loss of strength when walking; pulse irregular, gen- 
erallv slow and full, alternating with small and frequent beats. 
Worse in the morning and night; also when eating, standing, 
or at rest. Better from motion. Right side. 

Digitalis. — Great anxiety, and inclination to shed tears; 
gloomy and peevish; blueness of the eyelids; swelling of the 
lower lids; hissing before the ears, like boiling water, with 
hardness of hearing; pale face, with blueish hue under the 
pale skin; convulsions on the left side of the face; faintness 
and debility with perspiration; great nervous weakness; pulse 



220 ELEMENTS OF SURGICAL PATHOLOGY 

is very slow, especially when at rest; pulse irregular and 
intermitting; while moving about the pulse is accelerated; 
internal chilliness with external heat; chilliness with heat and 
redness of the face; sudden flushes of heat, followed by great 
debility. Worse after dinner. Better when lying down. 

Elaterium. — Depression of spirits, fever with violent tear- 
ing pain throughout the head. Better from perspiration. 

Euphrasia. — Taciturn, disinclined to talk; swelling of the 
lower eyelids; redness of the face; stitches and stiffness in 
the cheek and lower jaw when talking or chewing; crawling 
as of a fly in one or other of the limbs, from below upwards 
in a straight line, with numbness of the part. Worse in the 
evening; also when wet. Left side. 

Ferritin. — Anxiety, as after committing a crime; quarrel- 
some disposition; inflammation and redness of the eyes, with 
burning and stinging; pale bloated face, especially around the 
eyes; fiery redness of the face, the veins are enlarged; pale 
face with red spots; unquenchable thirst; longing for acids;, 
weakness of the body almost paralytic; so weak that she 
must lie down; pulse full and hard; violent ebullitions. Worse 
in the morning; also when at rest. Better "from slow exercise. 
Left side. 

Gehemium. — -Great irritability, does not wish to be spoken 
to; aversion to light, particularly candle-light; heat in face, 
with fullness in head, and cold feet, stiffness of the jaws — 
they are locked; pulse slow, accelerated by motion. Loss 
of. control, like chorea. Worse at night; also on walking. 

Graphitis. — Melancholy, with inclination to grief; easily 
vexed; pressure and stinging in the eyes, with lachrymation; 
feeling as if the ear were filled with water; pale, yellow color 
of face; continued feeling as if from a cobweb over the face; 
violent thirst, early in the morning; pulsation through the 
whole body whenever he moves; pulse full and hard, but not 
accelerated; inability to perspire. Worse at night; also from 
cold. Better from warmth, and on getting warm in bed. 

Gratiola. — Serious, taciturn, absorbed in reverie; burning 
heat in the face; face feels swollen; violent thirst; physical 



TREATMENT OF NEURALGIA 221 

and mental depression: great languor and prostration; tetanic 
spasms, feeling bruised on recovery. Worse in the afternoon; 
also when sitting, and after eating. Better from contact. 

Hepar sulph. — The slightest cause irritates him, and makes 
him vehement: dejected, sad, with inclination to shed tears; 
inflammation of the eyes and lids; darting pains in the ears; 
redness and heat of the nose; heat and fiery redness of the 
face; yellow color of the face, with blue borders around the 
eves; fainting from slight pain; weakness of all the limbs. 
they feel bruised; pulse full, hard, and accelerated, at times 
intermittent; flushes of heat, with perspiration. Worse at 
night; also from cold, and on touching the parts. Better 
from warmth, when part is well wrapped up. 

Hyoscyamus. — Red, sparkling eyes; heat and redness of 
the face; swollen, brown-red face; distorted blueish face, with 
the mouth wide open; repeated attacks of fainting; subsultus 
tendinum; pulse full, hard, and accelerated; distention of the 
arteries; cold, sour-smelling perspiration. Worse in the even- 
ing; also after eating or drinking. Better by stooping. 

Hypericum perf. — Sensation as if the head became elon- 
gated; stitches in the right eye; shooting through the ear; 
the face feels hot and bloated; tension in the cheek; thirst 
with feeling of heat in the mouth; violent thirst; feeling of 
weakness and trembling in all the limbs; pulse hard and 
accelerated. Great soreness and sensitiveness. Worse in the 
afternoon; also after eating. ( Vide Lippe, p. 294, symp. 39, 
for lacerated wounds of nerves especially.) 

Ignatia. — The slightest contradiction irritates; intolerance 
of noise: cannot bear the glare of light; alternate redness 
and paleness of the face; redness and heat of one cheek and 
ear; perspiration only on face; trembling of the limbs; pulse 
hard, full, and frequent, or very variable; flushes of heat 
externally. Worse in the morning and evening; also when 
lying down, from coffee, tobacco, and brandy. Better when 
lying on the back, and from a change of position. 

Ipecacuanha. — Irritability, restlessness, impatient; cannot 
bear the least noise; pale face, with blue margins around the 



222 ELEMENTS OF SURGICAL PATHOLOGY 

eyes; convulsive twitches in the muscles of the face and lips; 
opisthotonos, and emprosthotonos; great weakness, and aver- 
sion to all food; over-sensitiveness to heat and cold, twitch- 
ing in the limbs; the body is stretched out stiff; pulse very 
frequent, but at times scarcely perceptible; damp coldness of 
the hands and feet. Worse at night. Right side. 

Iris vers. — Pain intense, with nausea, and vomiting of 
sweetish mucus. 

Kali bich. — Ill-humor, low-spirited, indifferent; sudden at- 
tacks of giddiness on rising from the seat; eyelids burning 
inflamed and much swollen; cedematous swelling of the eye- 
lids; sensitive painfulness of the bones of the face, as if bruised; 
perspiration on the upper lip; increased thirst; stiffness of the 
neck when bending the head forward; quickly moving, wan- 
dering pains, from one part of the body to the other; great 
debility, with desire to lie down; pulse small and accelerated; 
hot, dry skin. Worse in the morning, and periodically; also 
from cold, and after eating. Better from warmth. 

Kali carb. — Angry, and irritable ; easily startled, especially 
if touched; painful sensitiveness of the e}'es to the light of 
day; dullness of hearing; dullness of smell; face bloated; yel- 
low color of the face; swelling and redness of the cheeks; 
twitching of the muscles; pulse very variable; strong pulsations 
in the arteries; internal heat, with external chilliness; the per- 
spiration is foetid or smells sour. Worse in the morning; also 
in cold air and when lying on the side. Better from warmth. 

Kahnia lat. — Sensation of stiffness around the eyes, and in 
the lids; coryza, with increased sense of smell; paleness of the 
face; stitches and tearing in the lower jaw; pulse slow and 
weak; heat, with burning and pain in the back and loins; cold 
perspiration; dry skin. Worse in the evening; also in the 
open air, and from motion. Better when lying down. 

Lachesis. — Nervous irritability; paleness, 3-ellowness, or 
lead-like color of the face; heat and redness of the otherwise 
pale face; great thirst; stiffness of the neck; tearing, prick- 
ing, and pulsating pains; inclination to lie down, and aversion 
to move; pulse small and weak, but accelerated, or else un- 



T I J E ATM ENT of n eura lgi a 



223 



equal and intermittent, or alternately full and small pulse; skin 
of the part blueish-red, Worse in the evening; also in the open 
air. from cold and after sleep. Belter from warmth. Right 
side. 

Ledum pal. — Great coldness, both subjective and objective. 

Lyeopodium. — Low-spirited, taciturn, melancholy; over- 
sensitiveness of hearing; the same in regard to smell; paleness 
of the face; flushes of heat in the face; spasmodic twitching in 
the muscles of the face; the lower jaw hangs down; painful 
stiffness and soreness of one side of the neck; involuntary 
alternate contraction and extension of the muscles in different 
parts of the bodv; sensation as if the circulation stood still; 
want of natural heat; violent perspiration from the least exer- 
tion; constricted feeling in part. Worse in the evening; also 
when lying down, from the pressure of the clothes, and strong 
smells. Better from cold. Right side. 

Magnesia earb. — Anxious, with perspiration all day; sad 
mood, with indisposition to talk; sensitiveness to noise; pale 
face; earthy, sickly complexion; alternate redness and paleness 
of the face; desire for acid drinks; stiffness of the neck; pain- 
fulness of the whole body; pulse slightly accelerated during 
the night. Worse at night; also from talking, or mental emo- 
tion. Better. — Symptoms are better from walking, which 
come on while sitting, and vice versa. 

Manganuni. — Out of humor, low-spirited, and reflective; 
eye-lids swollen, and painful to the touch; face pale and 
sunken; twitching stitches from lower jaws to temples when 
laughing; cramping pain in the upper and lower jaws after 
eating; no thirst; stiffness of the nape of the neck, pulse very 
uneven and irregular; sudden flushes of heat in the face, chest, 
and over the back; profuse perspiration, with short anxious 
breathing. Worse at night; also on stooping, and on being 
touched ever so lightly. Better. — Symptoms are better in the 
open air, which come on in the room, and vice versa. 

Mercurius. — Copious perspirations, which do not afford any 
relief; sweat at every motion; violent thirst, swelling, redness 
and closing of the eyelids; feverish heat and redness of the 



224 



ELEMENTS OF SURGICAL PATHOLOGY 



face; swelling of the cheeks; almost complete immobility of 
the jaw; swollen and stiff neck, with difficulty of turning the 
head; painful closing of the jaws. Worse in the evening and 
night; also from the heat of the bed, when exercising, and in 
damp weather. Better when at rest, and when lying down. 

Mezereum. — Restlessness when alone, and longing for com- 
pany; twitching of the muscles around the eyes; visible 
twitching on the root of the nose; gray, earthy complexion: 
frequent troublesome twitching of the muscles in the middle 
of the cheek; face and forehead hot and red, with great rest- 
lessness and pevishness; tension of the muscles; twitching of 
muscles; pulse full and hard, in the evening accelerated; sen- 
sitive to touch. Pains come on like electric shocks. Worse in 
the evening, and at night; also from contact and motion. 
Better when walking in the open air. 

Moschus. — Great anxiety, with palpitation of the heart;, 
vertigo as soon as the head is moved; pale face, with perspira- 
tion; the right cheek is red without heat, the left pale and hot; 
heat in the face without redness; tension in the facial muscles 
as if too short; movement in the lower jaw as if he were 
chewing; great dryness of the mouth; pulse full and acceler- 
ated, with ebullitions, or weak pulse. Worse in the afternoon, 
also in cold air. Better from warmth. 

JSfatnnn mur. — Great tendency to start; difficulty of think- 
ing; face shining, as if greasy; heat in the face; swollen face; 
tingling and numbness of the lips; tension and drawing in the 
back part of the head; painful stiffness of the neck; twitching 
in the muscles and the limbs; pulse very irregular; beating of 
heart shakes the whole body. Worse in the morning; also 
from physical exertion. Better when fasting, and after lying, 
down. 

Nitric acid. — Sadness, despondency, vexed at trifles; eyes 
dull and sunken, with pale face: swelling of the cheeks; vio- 
lent thirst; stitches in and between the shoulder-blades, with 
stiffness of the neck; flushes of heat with perspiration on the 
hands; pulse very irregular, one normal beat often is followed 
by two small rapid beats, the fourth beat entirely intermitting; 



TREATMENT OF NEURALGIA 225 

alternate hard, rapid, and small beats. Worse in the evening, 
and at night; also on waking, and from touch. Better from 
warmth. 

Niix votn. — Over-sensitiveness to external impressions, such 
as noise, light and smell; reeling vertigo on rising from seat or 
the bed, or on raising the head; yellowness around the mouth 
and nose, or around the eyes; red, swollen face; burning red- 
ness of the face, with heat; the muscles of the face twitch in 
the evening when lying down; trismus; longing for brandy, 
but aversion to water; tension between the shoulder-blades; 
sensation in the small of the back, as if lame; heaviness and 
stiffness of the neck; stitches in jerks through the whole body- 
pulse full, hard, and accelerated, or small and rapid, or every 
fourth beat intermits; general internal heat. Morose, irri- 
table; tearing with numbness. Worse in the morning; also 
from motion and slight touch, on waking in the morning, and 
after eating. Better from strong pressure. Right side. 

Oleander. — Absence of mind, want of attention; vertigo on 
rising from the bed, or on looking fixedly at an object, or 
when looking down when standing; alternate paleness and 
dark redness of the face; numbness of the upper lip; much 
thirst, especially for cold water; fainting as if from weakness, 
relieved by perspiration; pulse very changeable and irregular. 
Worse at night; also when rising from the bed, and when eat- 
ing. Better when lying down, and from perspiration. 

Opium. — Stupid indifference; stupefying vertigo, compel- 
ling one to lie down; the eyes are half open and turned 
upwards; swelling of the lower lids; the eyes feel too large 
for the orbits; the face is bloated, dark-red, and hot; blueish 
face; trembling, twitching, and spasmodic movements of the 
muscles of the face; corners of the mouth twitch; distortion of 
the mouth; hanging down of the lower jaw; the veins of the 
face are distended; violent thirst; the body is spasmodically 
bent backwards; rigidity of the whole body; pulse varies very 
much; heat with damp skin. Worse at night; also on rising, 
during and 'after sleep. Better from moving. 

Petroleum. — Excited, irritable, with inclination to anger; 

Q 



226 ELEMENTS OF SURGICAL PATHOLOGY 

3 T ellow complexion; twitching in the limbs; great debility, with 
trembling; pulse full, and accelerated from every motion; 
flushes of heat. Worse in the morning and evening. Better 
from warmth. Right side. 

Phosphorus. — Great excitability, easily vexed and angry; 
pale, hypocratic countenance; the color of the face is very 
changeable; bloated face, puffiness under the eyes; eyes are 
sunken, with a blue ring around them; thirst, stiffness in the 
neck; over-sensitiveness of all the senses; ebullitions and con- 
gestions; pulse generally accelerated. Worse in the evening, 
and at night; also when alone, and from strong smells. Bet- 
ter in the dark, from rubbing, and after sleeping. 

Phytolacca. — Great indifference; shooting pain from left eye 
to vertex; vertigo and dimness of vision; pale face; the pains 
are pressing, shooting and sore. 

Plantago. — Neuralgia from abuse of tobacco. 

Platina. — Low-spirited, inclined to tears, great indifference; 
spasmodic twitching and trembling of the eyelids; redness and 
burning heat in the face, with violent thirst towards evening; 
sensation of coldness, tingling and numbness in the face; pale, 
sunken countenance; thirstlessness; stiffness of the neck; 
weakness, tension, and numbness in the neck; pulse small, 
feeble; frequently it is tremulous; objects appear smaller than 
they really are. Boring, or pain, as if part were being- 
squeezed. Worse in the evening; also when at rest. Better 
during motion. 

Pulsatilla. — Peevishness, which increases to tears, with 
chilliness and thirstlessness; vertigo, as if intoxicated, when 
rising from the seat, when stooping, or when lifting up the 
eyes; swelling and redness of the eyelids; alternate redness 
and paleness of the face; face bloated, purple; painful sensi- 
tiveness of the skin of the face; stitches in the small of the 
back; burning-stinging pains; pulsation through the whole 
body; fainting, with great paleness of the face; pulse weak 
and small, but accelerated. Worse in the evening; also from 
warmth, and being in a warm room. Better from cold, and in 
the open air. Right side. 



TREATMENT OF NEURALGIA 227 

Rhus tox. — Restlessness which does not permit one to be 
quiet, and compels him to toss about in bed; swelling of the 
eyelids: aversion to light; face pale and sunken, with blue 
rings around the eves, and pointed nose: stiffness in the articu- 
lations of the jaws: thirst: inflammatory swellings; pulse 
irregular, generally faster. but weak. Worse'm the night; also 
when beginning to move, when at rest, and from cold. Better 
from motion and warmth. Right side. 

Rhus rod. — Excessive debility; restless nights; pulse fre- 
quent and small; confusion of the head; redness and swelling 
of the eyelids, with itching and burning; burning in the face, 
with redness and itching; vesicles on the face; thirst at night; 
pain and rigidity in the posterior lumbar region; muscles of 
the neck pained by movement, and sensitive to pressure. 
Worse when beginning to move. Better when walking in the 
open air. When the Rhus tox. fails to cure, although appar- 
ently well indicated, I advise the use of this remedy. 

Ruta grav. — Anxious and low T -spirited; inclination to quar- 
rel and contradict; great heat in the head, w r ith much restless- 
ness; spasms of the lower eyelids; violent thirst in the after- 
noon: pulse only accelerated during the fever; heat in the 
face, with red cheeks, and cold hands and feet. Pain in nerves 
that have been stretched, as in sprains. Worse in the after- 
noon; also in cold weather, when sitting, during rest. Better 
from motion. Left side. 

SabadiUa. — Anxious restlessness, startled by noise; burn- 
ing heat and redness of the face; great debility, with relaxa- 
tion or heaviness of the body; pulse small and spasmodic. 
Worse in the forenoon, and at night: also from cold. Better 
from warmth. 

Secede. — Great anxiety: distortion of the eyes; dark red- 
ness of the face; spasmodic distortion of the mouth and lips; 
violent, unquenchable thirst; convulsive twitching in the limbs; 
pulse unchanged, even in the most violent attacks; violent, 
and long-continued dry heat, with great restlessness and 
violent thirst. Worse at night; also from warmth, touch and 
motion. Better from cold, and rubbing. Right side. 

Q 2 



22 8 ELEMENTS OF SURGICAL PATHOLOGY 

Sepia. — Sadness, with weeping; anxiety, with flushes of 
heat; neuralgic pains from abuse of tobacco; swelling of the 
upper lip; stiffness in the small of the back and neck; pulsa- 
tions in the small of the back; inflammatory swelling, vibrations 
like dull tingling in the body; the pulse is full and quick, 
accelerated by motion and anger; pulsation in all the blood 
vessels. Jerking like electric shocks. Worse in the forenoon 
and evening; also from mental emotions, when at rest, and 
after eating. Better from warm air, and violent exercise. 

Silicea. — Pale, earth-colored face; jaws spasmodically closed; 
spasmodic pain in the small of the back, which does not 
allow one to rise; twitching of the limbs day and night; pulse 
small, hard, and rapid; the circulation is easily excited; pers- 
piration only on the head. Worse in the night; also in the 
open air, from cold, and pressure. Better from warmth. 
Right side. 

Shigella. — Difficulty of thinking, and disinclination to mental 
exertion; giddiness when looking downwards; vertigo with 
nausea; sensation as if the eyes were too large; pale, bloated, 
and distorted face; perspiration on the face; periodical face- 
ache; pains burning, and tension, especially in the cheek- 
bones, above the eyebrows, in the eyeball, and in the left side; 
violent thirst; pulse irregular, generally strong, but slow; 
trembling pulse; cold perspiration. Acute pain, better from 
strong pressure. Worse in the forenoon, and at night; also 
from noise, movement, touch, and stooping. Better after lying 
down. Left side. 

Stannum. — Great anxiety and restlessness; vertigo; it seems 
as if all objects were too far off; burning-stitches in the eye- 
lids; pale sunken face, with deep-sunken eyes; pulse small 
and quick; anxious sensation of heat from the least move- 
ment; pains which increase gradually to the maximum and 
then gradually decrease. Worse in the evening; also after 
moving, and from talking. Better from loosening the gar- 
ments, and when lying on the back. Left side. 

Staphysagria.- — -Weakness of memory; countenance sunken, 
with sunken eyes, and peaked nose; blue margins around the 



TREATMENT OF NEURALGIA 229 

eyes; violent upward stitches in the back; twitches at night; 
pulse verv fast, but small and trembling. Worse about the 
same all times of day. except evening. 7>etter in evening. 
Rijjht side. 

Stramonium, — Very changeable disposition; red, inflamed, 
swollen eyes; contortion of the eyes and eyelids; red, swollen, 
and turgid face; stupid, distorted countenance; anxiety and 
fear is expressed in the countenance; distortion of the mouth; 
violent thirst, drinking large quantities; body bent backwards, 
with distorted countenance; pulse very irregular, generally 
small, hard, and quick; hot. red face, with cold hands and feet. 
Worse in the morning; also after sleep, from touch, and when 
alone. Better from bright light. 

Sulphur. — Peevish and irritable; face pale; circumscribed 
red spots on the face; red blotches on the face; sunken eyes, 
with blue margins; trembling and twitching of the lips; cold 
perspiration on the face; constant thirst; stiffness in the neck; 
drawing in the back; pain in the small of the back, not permit- 
ting one to stand erect; great debility and trembling, talking- 
fatigues; pulse full, hard, and quick, at times intermitting; 
swollen veins; cold nose, hands, and feet; dry heat with thirst; 
flushes of heat; perspiration easily excited, or w r ant of per- 
spiration. Worse in the evening; also on w 7 aking, or getting 
warm in bed, from bodily exertion, talking, when at rest, and 
from being touched. Better from motion. Left side. 

Teucrium. — Great sensitiveness and excitability; pale face; 
frequent feeling of flushes of heat, without redness; nervous 
excitability; trembling sensation of the whole body. Worse'm 
the forenoon, and at night; also on stooping, and to the touch. 
Right side. 

Thuja, — Over-excited; becomes angry at trifles; vertigo on 
closing the eyes, disappears on opening them; heat and red- 
ness of the w r hole face, with fine nets of veins, looking as if 
marbled; circumscribed burning redness of the cheeks; 
greasy skin of the face; swelling of the temporal arteries; 
neuralgia, originating in the left cheekbone, near the ear, 
extending through the teeth to the nose, through the eyes into 



230 ELEMENTS OP SURGICAL PATHOLOGY 

the temples, and into the head; the painful places burn like fire 
and are very sensitive to the rays of the sun; violent thirst; 
beating and pulsating in the back; jerking in the upper part 
of the body; pulse in the morning slow and weak, in the 
evening accelerated and full; in the evenings, violent pulsa- 
tion; swelling of the veins. Worse in the morning, evening, 
and at night; also from cold-wet and the heat of the bed. 
Better from warm-wet, and on turning from the left to the 
right side. 

Valerian. — Very changeable disposition; redness and heat 
of the cheeks, especially in the open air; over-sensitiveness of 
the cheeks, especially in the open air; over-sensitiveness of all 
the senses; pulse irregular. Worse in the forenoon, and 
towards evening; also while reposing, when standing, and iiu. 
the sun. Better in the light, and from motion. 

Veratrum. — Vertigo, with cold head; perspiration on the 
forehead; face pale, blueish, cold, disfigured, like death; blue 
or green circles around the eyes; spasms of muscles when 
masticating; violent, unquenchable thirst, particularly for cold 
water; back and small of the back feel sore and bruised; 
sudden sinking of strength; shocks in the limbs, as from elec- 
tricity; spasms, with convulsive motions of the limbs; tetanic 
stiffness of the body; pulse irregular, generally small and 
thread-like, and weak; slow pulse, often it cannot be felt at 
all; perspires easily from the least exertion. Worse in the 
morning; also after sleep, and during perspiration. Better 
after perspiration. 

Vifteri redi. — Opisthotonos; cold sweat; restlessness; fre- 
quent vertigo; protruded eyes; face swollen; oppression of 
chest. 

Zincum. — Very variable mood; paleness of the face; stiff- 
ness and tension of the neck; pulsations through the whole 
body; violent trembling, twitching of the body; pulse small 
and rapid in the evening, slower in the morning and during the 
day; pulse at times intermitting; violent pulsations in the 
veins; flushes of heat, with trembling, and short, hot breath; 
badly-smelling perspiration; perspires easily during the day, 



TREATMENT OF NEURALGIA 231 

and on exercising. Burning; quick stitches and jerking; can- 
not keep quiet; in constant motion. Worse in the afternoon 
and evening; also after eating, in the warm room, and from 
least touch. Better in the open air. 

An agent of very great efficiency, so say those who hava 
had experience with it, is Electricity, in some of its forms. 
Butler {Electro Therapy p. 100), thus speaks of it: 

•• 1. The whole of the trunk of the affected nerve must be 
included in the circuit. 

'•2. Regularity of applications, which in all cases ought to 
be repeated at hast daily. These conditions being observed 
it matters little whether the current be transmitted in an 
ascending or descending direction." Going on to state that 
either galvanism or Faradism may be used, he gives the fol- 
lowing rules: 

••1. That whatever form of current be used, only the very 
mildest intensities are curative. 

••2. That a large percentage of cases are cureable by a 
strict attention to this rule. 

••3. That high intensities of either form of current produce 
serious aggravations. 

•• 4. That a certain proportion of cases yield to the galvanic 
current, that cannot be cured by the Faradic, and vice versa. 

••5. That it is impossible always to tell beforehand, which 
form of electricity will cure any given case, any more than we 
can always tell which potency of a drug remedy is the proper 
one to use. 

•• 6. That there are undoubtedly a small proportion of cases 
that will yield to neither form of current administered alone, 
that will rapidly improve under a judicious alternation of the 
forms. 

••7. That the number of cases which entirely resist every 
form of electrical treatment is very small indeed. 

i; 8. That where the nerve is deeply seated, electro-puncture 
of the sheath, or even of the nerve itself, becomes necessary, 
as otherwise recomposition takes place in the more superficial 
structures, without the current reaching the nerve at all. 



232 ELEMENTS OF SURGICAL PATHOLOGY 

This operation must be performed by a thorough expert in 
electro-therapeutics, as without the greatest skill being 
exhibited, electrolysis of the nerve takes place, which is not 
only fatal to success, but disastrous in its consequences. 

"9. A Brenner's rheostat should always be used in the 
circuit; also a galvanometer, for obvious reasons." 

Such is the summary of one whom I believe to be a 
thorough expert in electro-surgery, and my limited experience 
has led me to fully endorse the views expressed. Neverthe- 
less, as we learn more of electricity, we shall come to know 
the indications as accurately as any other medicinal agent in 
common use. It is the indiscriminate and ignorant use of this 
remedy that has brought it somewhat into disrepute. 

NEURITIS. 

Neuritis is an inflammation of a nerve, a development from 
a neuralgia. The passage from a state of irritation to one of 
inflammation is a very gradual one, and it is doubtful if the 
exact time of the change can be diagnosticated in any case. 
There are still periods of exacerbation, with remissions, very 
like the semeiology of neuralgia, but there are certain patho- 
gnomonic symptoms, both during the paroxsyms and the remis- 
sion, that never occur in simple neuralgia. In the periods of 
remission the nerve is sensitive to pressure or irritation, which 
never occurs in pure neuralgia. Putting the nerve on the 
stretch will always be painful, as is conveniently shown in 
sciatica; the extremity being full} 7 extended, is flexed on the 
body, keeping the leg straight — and the tension of the nerve 
will always cause sharp pain. In neuralgia such a procedure 
would probably bring on an attack, but the manipulation itself 
would not be painful. The repeated attacks of inflammation 
cause pain of equal severity to those of neuralgia, which does 
not pass off as suddenly or completely; later there is only a 
partial remission, more or less pain being felt at all times. 
The results, as to the structural integrity of the nerve are 
various, depending on conditions not yet understood. In some 
cases the nerve becomes notably enlarged; in others atrophied; 



TREATMENT OF NEURITIS 



233 



in some cases again it undergoes a softening degeneration, and 
in still others beeomes sclerosed. In a few instances neo- 
plasma form, either in the substance of the nerve, within the 
nerve, within the neurilemma, or outside, but attached to the 
sheath. 

The effects on the function of the part are likewise various. 
Thus when motor fibres are chiefly affected, choreic symp- 
toms predominate; under all circumstances there will be, after 
a time, notable loss of power or function, as degenerative 
changes occur. 

One symptom should not be forgotten, viz., the signs of 
inflammation, during a paroxysm, very different from what 
obtains in a simple neuralgia. 

The Pathology will be more appropriately referred to later, 
and thus avoid repetition. It is sufficient to state at this time, 
that the tendency of neuritis is to destruction of the nerve by 
trophic or degenerative changes, which must result in loss of 
function of all parts or organs under its influence. 

The Treatment must often be surgical, but not so frequently 
as some writers would have us believe. Of course if the 
practitioner allows a case of neuralgia to pass over into a 
neuritis, he has lost an opportunity. However, many cases 
are brought to the surgeon after the development of the inflam- 
mation, and he is obliged to take the case as he finds it. The 
indicated remedy is a potent curative agent, so much that 
patience in securing indications will rarely fail in conferring 
the reward. There are cases, however, as was stated under 
inflammation, when other means must be employed, but the 
detection of the lesion is not difficult, as a rule, the pain being 
distinctly localized. A neuritis due to inclusion of a nerve in 
a scar, or the like injury, must always demand its release, and 
yet even in such cases Silicea has more than once loosened 
such adhesions in a surprising manner. 

The remedies indicated are those already given under neu- 
ralgia, to which reference may be had. 



234 



ELEMENTS OF SURGICAL PATHOLOGY 



ATROPHY OF NERVES. 

Atrophy of a nerve is brought about in the same way that 
atrophy of any tissue is, viz., by cutting off its blood-supply, 
not suddenly, but by a gradual diminution. This may be a 
result of inflammation, with fibrinous exudation; over-tension 
of a nerve, in various ways; pressure, or by section. In this 
last case it is the distal portion that atrophies. The wasting is 
supposed to be more rapid in the axial substance, arid yet it 
is possible that all the structures suffer cotemporaneously. 
There will be a progressive loss of function, as the process 
goes on, with complete paralysis when the nerve is destroyed. 
The symptoms are not at all recognizable, the progressive 
paralysis being the same in sclerosis or softening. 

HYPERTROPHY OF NERVES. 

Hypertrophy is a result of hyper-nutrition, a gradually 
increased vascularity, which may be secondary upon neuritis, 
or due to some obstruction in the circulation elsewhere. An 
example, perhaps, may be found in the nerves of the stump, 
after amputation. The symptoms are those of neuritis, usually 
not of a high grade, and at the most a diagnosis can only be 
a more or less intelligent guess In many cases hypertrophy, 
itself a sequel to neuritis, is but the first step in further change, 
such as softening or sclerosis, perhaps oftener the former. 

SOFTENING OF NERVES. 

A Sudden and complete cutting off of the blood supply to 
a nerve, or a portion of it, will have the effect to cause des- 
truction of the organ by a breaking down of the proper nerve 
elements, which are ultimately carried away by absorption, 
followed by atrophy of the fibrous frame-work. The result is 
the same, in the end, as atrophy above described, the process 
being more rapid in proportion to the suddenness with which 
the blood-supply is cut off, or in other words its completeness. 

SCLEROSIS OF NERVES. 
Sclerosis or hardening of nerves, is due to an inflammation 



SCLEROSIS OF NERVES 235 

confined to the sheath or other part of the fibrous frame-work, 
of a low intensity, which determines a fibrinous or plastic 
growth inwards. The result is in another form of atrophy, 
the nerve being' converted into a fibrinous cord, by cennective- 
tissue proliferation inwards, and destruction of the nerve-ele- 
ments by compression. 

The Teatment of these degenerative processes cannot be 
given in any detail. In many of them, surgery, pure and 
simple, is the only recourse; in others the symptoms furnished 
in each case, must be the guide for selection of a remedy. In 
still others the pathological state, if it can be determined, will 
alone give the remedy. Thus, if due to cicatricial compres- 
sion, Silicea will be first considered, regardless of symptoms. 
If sclerosis can be made out, Argent nit., Picric ac, or Oxalic 
acid will claim attention. The limits and plan of this work 
forbid a full account of the therapia, as the necessary indica- 
tions are obscure and would require a volume to elucidate. 
The purpose of this chapter will be fulfilled, if attention is 
directed to the importance of considering neuralgia a prodroma 
of these late lesions, and thus prompting the practitioner to a 
careful consideration of every such case that may be pre- 
sented to him. 



XVI— VENEREAL CONTAGION 

Notwithstanding there is good reason to believe that 
venereal diseases, in some form at least, have existed ever since 
the first appearance of man on earth, and have consequently at 
all times been a subject of interest to the human race, there is 
very much, of vast importance, still unknown as to exact 
causation. As far as mere description is concerned the sub- 
ject is an easy one to handle, yet there is a remarkable differ- 
ence, in many cases, between the symptoms and appear- 
ences as met in actual practice, and the accounts given in the 
books. As some one has said: " nothing is so easy to diagnose 
in the books, and so hard to diagnose in the case." The chief 
difficulty, of course, is in correctly appreciating etiology; and 
next, and only second in importance, classification. As to 
etiology the difficulties, perhaps, are not greater than obtain 
in other forms of morbid action, but from some cause they 
have a magnitude apparently greater than ordinary. It is 
possible that a realization of the importance of correct knowl- 
edge, with such direct relation to the welfare of the race, has 
had much to do with rendering the subject particularly obscure. 
However that may be, or whatever the true reason, certain it 
is that there is no subject in the whole catalogue of morbid 
affections of which the literature is so perplexing and bewil- 
dering. 

By venereal diseases strictly speaking, is meant any malady 
originating in, or having relation to the sexual act; in a more 
restricted and conventional sense, it refers to specific contagion 
from sexual commerce with those who are subjects of specific 
disease. For purposes of comparison it will be necessary, in 
236 



VENEREAL CONTAGION 237 

the present chapter to give some attention to at least one form 
of morbid action that is neither specific nor necessarily venereal, 
lief ore doing so, however, it will serve a useful purpose to 
define "specific" and " contagious," in the sense it is proposed 
to use the term. A specific disease is one that runs the same 
course, arises always from the same cause, has the same natural 
history in all cases, varying only in the intensity of some of 
the svmptoms in different cases. It has a relation to conta- 
giousness in that the morbid action may be extended to other 
unprotected individuals, by means of its products. Under 
this head would be included not only gonorrhoea, chancroid, 
and syphilis, but tuberculosis, erysipelas, and many other 
diseases not essentially surgical in character. 

Contagiousness is the property of infecting an organism 
bv contact with some active morbific agent, originating out- 
side of the organism, and communicating the same toxic capac- 
ity to the products of the disease. Thus small-pox, glanders, 
and the specific venereal diseases, may be communicated to 
an unprotected organism from without, and the products of 
the disease will excite the same morbid phenomena in another 
individual, the conditions being favorable, without any abate- 
ment in virulence. The term is used, therefore, with the 
ancient significance, viz., contact. Contagion may be immedi- 
ate or mediate. It is the former when there is direct contact 
between the original subject, and the recipient, as would 
occur in sexual commerce. It is mediate, when the morbid 
agent is carried from one to another on articles of clothing, 
or the toilet, or in some similar way. Generally the potency 
of the morbid matter has a somewhat definite duration of life, 
and is influenced to a certain extent by conditions. Some of 
them are tenacious of life, and will remain potent for a long 
period when separated from their source. This is notably true 
of syphilis; less so of gonorrhoea. Heat, acids, strong alkalies, 
alcohol, and electricity devitalize all of them. Thus we find 
that certain forms of venereal contagion are more venereal 
than others; that is, they require sexual contact for develop- 
ment, particularly as some of them are chiefly found in the 



238 ELEMENTS OF SURGICAL PATHOLOGY 

genital passages. At this time it will be sufficient to note, 
that gonorrhoea is the most venereal, next chancroid, and least 
of all syphilis: but as to gravity, the order is reversed, syphilis 
taking the first rank. 

Bearing these definitions in mind, notwithstanding they will 
not meet with universal acceptance — we are now prepared to 
take up the study of the different forms of venereal contagion. 

NON-SPECIFIC URETHRITIS. 

This is an inflammation of the urethra in men. not depend- 
ent upon sexual commerce at all. that presents some of 
the characters of the specific form, so much so that it is a 
matter of necessitv to understand the chief features for pur- 
poses of differentiation, if for no other reason. In women the 
analogous condition is a similar inflammation of the vaginal 
mucous membrane, the cervix uteri, and possibly the urethra. 
The essential features of non-specific urethritis are as follows : 
More or less intense inflammation, running a rapid course, 
accompanied by a discharge, chiefly mucous in character, and 
subsiding rapidly in complete resolution, unless often repeated, 
when resolution becomes more imperfect, and there may be 
some enduring sequelae. There are two svmptoms of great 
value, as distinguishing from the specific form, clearly ex- 
pressed, but often very difficult to determine in practice, viz., 
absence of incubation, and the confinement of the inflamma- 
tion to the mucous membrane. 

The patient can often trace the commencement of the 
attack to a definite cause; such as exposure to cold or wet, 
injury of some kind, or sexual intercourse with one suffering 
from some form of leucorrhoea, or other vaginal discharge, 
sometimes a menstrual one. The symptoms of inflammation 
come on at once, or within a few hours, and rapidly reach a 
climax. In other cases, masturbation, the use of bougies or 
catheters, prolonged or frequently repeated sexual intercourse, 
cystitis, vesical stone, rectal or anal parasites, enlarged prostate, 
use of certain drinks, as beer, or of drugs such as asparagus, or 
a thousand and one causes that may irritate the urethra directly 



■\ SPECIFIC CJRETHR1TIS 239 

or by contiguity, arc provocative of an attack. In all cases, 
however, there is an absence of an incubatory stage, and in 
most instances a possibility of connecting the attack with some 
evident cause. There are many examples, however, particu- 
larly in crises arising from long continued irritation, in which a 
diagnosis seems well nigh impossible, and much injustice may 
be done the innocent sufferer. As far as therapeutics are 
concerned, it is a matter of indifference whether the case is 
specific or otherwise; but to protect others, to say nothing of 
moral considerations affecting the individual, it is a matter of 
the utmost importance that a correct diagnosis should be made. 

If examination can be had, the mucous membrane will be 
found swollen, red, irritable, bleeding easily, but soft and pli- 
able, moving freely over the deeper parts; in gonorrhoea it 
will be hard, leathery, and the sub-mucoid tissues partake in 
the inflammation, so that the parts seem infiltrated. The 
sensitiveness and irritability of the urethra make it intolerant 
of touch, so that strangury or even complete retention of 
urine occurs: at times this irritability causes spasms of the 
muscles, which may be exceedingly painful. In the vagina 
the same general features are marked, the puffy, swollen, red, 
and irritable mucous membrane being intolerant of touch, 
often the vulva is swollen and hot, sometimes the glands sup- 
purating. When the urethra is invaded the symptoms are the 
same as in men. In very many cases, it has been remarked, 
the inflammation commences deep in the urethra, in the vesical 
portion — and extends outwards to the meatus, just the reverse 
of the gonorrhoeal development, In my own cases this has 
always been looked upon as a diagnostic symptom of value, 
particularly when associated w r ith the character of the dis- 
charge, and the feeling'of the urethra, through the integument. 
The discharge is always more mucoid than purulent, some- 
times there being no pus-cells, or so few as to be insignificant; 
the corpus spongiosum feels swollen, it is true, but it is not as 
hard and leathery as in specific urethritis. 

The microscope gives little, if any aid in the diagnosis of 
non-specific urethritis; the question will be taken up again 



240 ELEMENTS OF SURGICAL PATHOLOGY 

later, under gonorrhoea; at this time it will be sufficient to note 
that the so-called gonococcus, at one time supposed to be the 
specific bacteroid, is now by many thought to be nothing more 
than a normal element in the vaginal secretions. Should there 
be an absence of pus-cells in the urethral discharge, the inflam- 
mation being of a high grade, the diagnosis would not be dif- 
ficult; with pus-cells present, particularly in any considerable 
number, as far as the microscope is concerned the evidence 
would still be inadequate. It is, therefore, the clinical testi- 
mony that is of diagnostic value, and this will be returned to 
when gonorrhoea is reached. 

Treatment is on general homoeopathic principles. The 
symptoms in each case are the only guide, and they differ so 
widely in different cases, owing to the variety of causes and 
personal peculiarities, that a full synopsis is impossible. In the 
majority of cases, however, when the patient applies early for 
relief, Aconite will be found the remedy indicated; in chroniq 
cases, or in late stages, some other remedy will be needed 
and the student is referred to the treatment of gonorrhoea. 

GONORRHOEA. 

There is an active controversy going on at this writing, one 
that has appeared and declined, at uncertain intervals, for 
many years — as to the the nature of gonorrhoea, or as it is 
otherwise called clap, gonorrhoea virulenta, or specific urethri- 
tis. Some esteem it to be at all times non-specific; others 
that it is just as invariably specific, and a few that the 
specificity is" due to a bacteria, the gonococcus. The last I 
shall dismiss in a few words, and by quoting from J. W. 
White, M. D. [Inter. Enc. of Surg., 11., p. 330, note 1) : "At 
intervals of a few years the doctrine of the dependence of 
gonorrhoea upon the presence and grow T th in the urethra of 
vegetable organisms — bacteria and micrococci — is revived and 
discussed. Neisser, Salisbury, Bokai, and lately Mr. 
Cheyne, Assistant Surgeon to King's College Hospital, have 
claimed to base their diagnosis and treatment of the disease 
upon the existence of these organisms. As their observations 



GONORRHOEA 



241 



have never been confirmed, except as to the discovery of 
micrococci Mich as are found in pus under all circumstances, 
and wheresoever derived, and as the antiseptic plan of treat- 
ment is usually a conspicuous failure in cases of gonorrhoea, it 
will not be necessary further to allude to these theories." 
Whilst this expresses my own views fully, and those of the 
majority of the profession, probably, it will need no elabora- 
tion. The same writer, however, in another place (p. 326) 
uses language which is not to be accepted without debate, and 
which I quote as a brief summary of the doctrine of the anti- 
specific party, with which I do not agree. •• Those diseases 
which are called ; specific,' and which are recognized as dis- 
tinct clinical or pathological entities, or as depending upon 
definite and invariable sources of origin, have, as a class, cer- 
tain peculiarities which more or less accurately characterize 
them; they have a period of incubation intervening between 
the time of exposure to infection and the outbreak of the first 
symptoms; they cannot be caused by traumatic influences or 
by anything except the essential virus of the disease, which, 
through some channel must find its way into the general circu- 
lation; they usually protect from a second attack; they are, in 
the majority of cases, accompanied by distinctive pathological 
changes or processes, which distinguish them from disease the 
result of mere irritative action; they run a definite course, and 
after their termination or subsidence, cannot be reawakened 

at will by any known agency In gonorrhoea, not 

one of these conditions obtains."' Now, on the other hand, I 
am of the opinion that the specific characters are easily de- 
monstrable, certain precautions being taken to guard against 
error. Thus, we will admit, that to the non-specific disputant 
there is a marked difference in the course, intensity, and ter- 
mination of cases that he indiscriminately calls gonorrhoea; it 
is here that the opposite party find their data. The virulent 
cases are gonorrhoea; the more benign are not. The differ- 
ences are as marked as in any two kinds of morbid action 
utterly different in natural history, the sole similarity consist- 
ing in there being a more or less purulent discharge from the 



242 



ELEMENTS OF SURGICAL PATHOLOGY 



genito-urinary canal. For convenience, therefore, I will take 
up each one of White's essential conditions of specificity, and 
endeavor to show that they are fully met in gonorrhoea. 

1. Our author says a period of incubation is essential to 
specificity, and certainly in gonorrhoea virulenta this condition 
is easily fulfilled. A period of from four to ten, or even four- 
teen days is commonly observed from the time of exposure to 
efflorescence. There are cases, unquestionably, in which the 
period is shorter, perhaps so short that incubation could be 
ignored; on the other hand, however, there are a few cases 
in w T hich it has been prolonged to fourteen days, and even 
longer. That syphilis is specific, in the most rigid acceptation 
of the word, none can question, and yet there are cases of 
undoubted authenticity, in w r hich the incubative stage seemed 
to be wholly absent. The fact, on this point, seems to be, 
that the receptivity of the individual has much to do with the 
length of the incubation as well as the virulence of the con- 
tagious element, and the conditions of the surface with 
which it is brought into contact. On an abraded surface, 
absorption of syphilitic virus would be so rapid that the incu- 
bation would be notably shortened, so much so that a doubt 
as to diagnosis might arise. There are other instances, outside 
of the genito-urinary sphere, in which the morbid condition is 
unquestionably specific, and yet incubation is absent. We are 
all familiar with cases of variola, and some have met cases of 
glanders, in which the prodromal symptoms occurred almost 
immediately upon exposure. As far as this question is con- 
cerned, the failure to observe the specific character is due to 
a neglect to differentiate urethritis. No one will asume that 
cases of urethritis are of even approximately equal severity, 
or identical semeiology. 

2. A specific disease, we are furthermore assured, cannot 
arise from traumatism. In a strict use of terms this is true, but 
actually it is not. Thus a person ma}' have gonorrhoea in an 
incipient stage, and an accidental irritation ma)- hasten the 
development. Such occurrences, however, are exceedingly 
rare, so much so that I have never met an instance. By 



(JOXOKRHCEA 



2 43 



Stretching the meaning of the term somewhat, the introduc- 
tion of pus. and its absorption by a mucous surface, is esteemed 
a species of traumatism. Accepting this, few practitioners 
have failed to have cases of mild conjunctivitis from contact 
with pus from neighboring- parts, the lachrymal canal: in 
many more instances the consequences of such contact are 
frequently negative, no svmptoms of any kind being produced. 
The clinical evidences are utterly opposed to the assumption 
that purulent inoculation, -per se, is the essential feature of 
gonorrhoea. Even should the source of the pus be the genital, 
surfaces, unless the discharge is gonorrhceal nothing more 
than ordinary irritation will result. This is not mere theory, 
as any medical practitioner can furnish instances of contact 
of mucous surfaces with non-specific pus from the genital 
passages, without any serious consequences, in most cases 
without any symptoms at all. All have seen cases of ophthal- 
mia neonatorum, of considerable severity, in w r hich the course 
is. as compared to gonorrhceal ophthalmia, sub-acute, and with 
none of the rapid destruction of tissue that characterizes the 
specific form. 

3. It is furthermore assumed that in true specific affections, 
future immunity must be the result. This is one of the rules 
that are to be proved bv the exceptions. It is not necessary 
to go into this argument at length, there being no lack of 
clinical testimony as to the repetition of contagious specific 
diseases, even many repetitions. Syphilis, the most specific of 
all diseases, has occurred more than once in the same individ- 
ual, although such an occurrence is admittedly exceedingly 
rare. No doubt the rule is as stated, but exceptions are 
plentiful. But there is more than this to be said of the 
prophylactic character of gonorrhoea. The tissue- changes — as 
will appear later — are of such a character, that renewed inflam- 
mation is easily set up, of such a type withal, that each recur- 
rence adds peculiarlv to liability to succeeding attacks That 
urethritis is easily induced in those who have had a gonorrhoea 
is true; it is far from being established that the urethritis thus 
set up, is of the virulent type. 

R 2 



2_j._| ELEMENTS OF SURGICAL PATHOLOGY 

4. A specific disease, we are also told, must exhibit some 
distinctive pathological feature. Surely such is eminently the 
case in gonorrhoea. A non-specific urethritis, no matter how 
acute or intense its character, can never furnish more than the 
ordinary characters of inflammation, proportionate to the 
intensity of the process. The parts are swollen, of course, but 
it is the soft compressible tumefaction of inflamed soft parts. 
In gonorrhoea, on the contrary, the parts are deeply affected, 
hard, almost cartilaginous and '-leathery," and slowly regain 
their normal characteristics. Like ail the contagious specific 
diseases, the contagious principle is in the pus-cell, which, so 
far, is indistinguishable from other pus-cells. No matter 
whether the discharge is the thin, serous fluid of the earliest 
stage, the thick purulent one of the second, or the viscid and 
albuminous of the last, inoculation is alike followed by gon- 
orrhoea, a fact that does not obtain in ordinary inflammations 
of these passages. Another specific character to the dis- 
charge, is found in the unique manner of its gradual disappear- 
ance. In ordinary inflammation, as the discharge diminishes 
in quantity, it becomes increasingly serous; in gonorrhoea it 
becomes viscid and gluey. A comparison of the symptoms, 
to be given in a later paragraph, will show these distinctive 
pathological characters more clearly. 

5. A specific disease must run a definite course, and if this 
alone were wanting to establish the specificity of gonorrhoea, 
the condition would be easily met. It will be seen that there 
are three well-marked stages, the lines of demarcation being 
clearly defined, and in each stage symptoms unique and patho- 
gnomonic. Even the sequela? are quite characteristic, perhaps 
not so much in themselves as in their consequences. A gon- 
orrhceal orchitis, for instance, is a much more chronic affair 
than the traumatic or idiopathic variety, but is chiefly notice- 
able from its tendency to run over into a sarcocele, or some 
permanent change of structure, and loss of function. 

6. The weakest point in the argument is found in the last 
statement of conditio sine qua non, that the disease (specific) 
cannot be reawakened by any other agency than the specific 



GONORRHOEA 245 

Ererm. i sav this is the weakest part, not because there is 
absence of clinical evidence, but because the facts obtained are 
equally potent on either side of the controversy. There has 
probably been an occasional instance of an attack of urethritis, 
presumably gonorrhoea, from some cause other than venereal 
contact: the prevailing mode, however, is from coition. Now 
here comes the difficulty. The party suspected of communi- 
cating the disease, may exhibit none of the symptoms, or even 
none of the history. The occurrence of the disease is thus 
accounted for: Either the suspected party has had gonorrhoea, 
the active symptoms of which have abated; or has recently 
contracted it. and active symptoms have not appeared; a pre- 
vious intercourse may have left some gonorrhceal virus in the 
genital canal: or the second party may have had intercourse 
with two or more parties, and some of the gonorrhceal virus 
may have been retained from the earliest. The difficulties 
experienced in settling such a problem in a given case, are due 
to the untrustworthy character of the evidence furnished by all 
the parties concerned, more particularly the one suspected. 
The possibility of mediate contagion must not be lost sight of. 

From an unprejudiced stud)' of the subject, uninfluenced 
(as far as possible), by the weight of great names, it seems 
impossible to question the specific character of gonorrhoea; the 
tendency of the rank and file of the profession, from the very 
earliest times, has always been to greedily accept novelties, 
and it is probable — judging the future from the past — that 
in a few years there will be a reaction from the teachings of 
to-day, and gonorrhoea restored to its old position, among the 
specific venereal diseases. At all events I shall treat the sub- 
ject from that stand-point, my experience affording ample justi- 
fication for what, at the moment, is no doubt a medical heresy. 

Semeiology. — The symptoms, it will be observed readily, 
fall into three groups or stages. The first is known as the 
stage of incubation, the second, acute inflammatory ', the third, 
chronic inflammatory. 

I. Incubation is marked and unmistakable. From three 
to five days after exposure, ordinarily, sometimes a longer 



246 ELEMENTS OF SURGICAL PATHOLOGY 

period — there will be a sense of heat with some smarting of 
the meatus, soon followed by slight swelling and itching. On 
inspection the margins of the orifice will appear tumid, some- 
what as though everted, and even in this early stage, hard and 
firm; urination is somewhat painful, at the meatus, the smart- 
ing caused thereby continuing for some time afterward. If 
the prepuce is long, it will also seem thickened, sensitive and 
less elastic than common. On making pressure along the 
urethra, a drop of muco-pus may be pressed out. In women 
the symptoms are similar, depending upon the part involved; 
usually all the mucous surfaces, lining the labia, the vagina, 
and often the urethra are swollen, sensitive and sometimes dry 
at first, later a scanty muco-purulent discharge. These symp- 
toms will gradually increase in intensity, until about the third 
day they assume the characters of the second stage. 

If the case is seen in this stage, in nine cases out of ten the 
whole process may be aborted. Aconite takes first rank, and 
in the first twenty-four hours may be considered almost a 
specific. After this period, some other remedy will be needed, 
that which has done me the most service being Apis. It is 
the fashion, or was very recently, to treat this stage with 
weak solutions of JYitrate of silver, by injection. In my own 
practice I think I have learned that such a course will quite 
surelv give unpleasant sequelae, stricture with long-continued 
gleet being the most common. Of course the discharge is 
lessened in amount by such treatment, but it is at the expense 
of future trouble. 

2. Acute Inflammation ushers in the second stage, in 
which the primary symptoms are wonderfully aggravated. 
The swelling gradually extends backwards along the corpus 
spongiosum, until at its maximum the urethra feels like a 
hard solid cord, which seems to be contracted so as to 
be considerably shorter than normal; it is sensitive to pres- 
sure, and painful if any attempt at extension is made. The 
corpus cavernosum is infiltrated, turgid, and more or less 
painful; the whole organ is thickened, and apparently short- 
ened. The discharge is profuse, in most cases, the puru- 



GOXOKR1HK \ 



247 



lent elements predominating over the mucus, yellow in 
color, not irritating, but with an odor I think eminently 
sm generis. The urine is frequently voided, sometimes with 
extreme strangury, always with pain, the swollen, narrowed 
and sensitive urethra giving the sensation as though it were 
molten metal; late in this stage there may be almost reten- 
tion, the urine coming in drops, mixed with blood, and causing 
a most intense suffering. Joined with it all, there is a most 

intolerable bitino--stino-ino- in the urethra, sometimes so intense 
000 ' 

that it drives the patient distracted. The heat, pain, painful 
urination, and the urethral itching combine to make the days 
miserable, and yet the night not unfrequently brings sufferings 
of its own. After the full establishment of the second stage, 
when warm in bed, there occur erections of the penis which is 
curved downwards, as though held with a bridle, causing 
intense suffering. This is known as chordee. It may occur 
during the day, but for many reasons is more likely to do so at 
night. As the inflammation extends deeper, there is heat and 
weight in the perineum, from involvement of the prostate, and 
occasional extension to the testicles, which will be referred to 
under the head of sequelae. The suffering, by day and night, 
being continuous, the bodily functions soon become deranged; 
sleep being broken adds to the derangement, so that such 
patients finally have a worn and haggard expression. In the 
natural history of the disease, unaffected by remedies, this stage 
will usually continue a fortnight. In women the second stage 
may involve all the mucous surfaces, resulting in metritis, endo- 
metritis, cystitis, or even, in aggravated cases, through the 
fallopian tubes, extend to the ovaries, or the pelvic cavity, 
giving rise to pelvic cellulitis. As a rule gonorrhoea, from 
the comparative simplicity of the structure of the parts in- 
volved, is productive of less suffering than among men; on 
the other hand, from the extensive surfaces exposed, in aggra- 
vated cases the condition is much more grave. 

Treatment is far more satisfactory if confined to the 
indicated remedy; the use of direct medication, no matter in 
what form applied, in my hands at least, has always been 



248 ELEMENTS OF SURGICAL PATHOLOGY 

unsatisfactory, even disastrous. This does not exclude the 
use of water, of different temperatures as may be desired, or 
even the application of heat or cold by other means. A very 
essential part of the treatment, indeed, is cleanliness, as nearly 
absolute as possible. Remembering the potency of the virus 
and the possibility of mediate contagion, the articles of the 
toilet must be out of the reach of others, even to the soap, 
and washing utensils; all cloths or towels, as well as articles 
of clothing that have come in contact with the discharges, 
should be burned. As a rule clear water, without soap, is to 
be preferred for ablutionary purposes, and from the sensitive- 
ness of the surfaces all harsh treatment must be avoided. 
The dressings should be frequently changed, as often, in the 
height of the disease, as once in two hours, or oftener, mak- 
ing it a rule to burn them as soon as removed. 

Diet must receive attention. Experience has shown that 
coffee, tea, alcoholic drinks, highly seasoned or spiced food 
all have a tendency to aggravate the local symptoms. So 
also occupation and exercise has a potent influence. Strictly 
sedentary habits are quite as injurious as too much activity, 
so that it may require some experiment, in given cases, to 
determine just how much, and w r hat kind of exercise is bene- 
ficial, or rather not hurtful. In the height of the disease there 
is little question that absolute physical rest is to be preferred. 

Therapeutics usually involves the study of a small number 
of remedies. Conceiving the disease to be specific, according 
to the teaching of Jahr and others, there should be a specific 
remedy. I think we have such a one in Apis; but as acci- 
dental circumstances may give modifications of symptoms, 
other and secondary remedies may be needed. Those that 
have done me the best service are; Apis, Arsen., Canth., 
Rims., Merc, or Bell., to these others have added: Gelsem,, 
Cann. sat., PetroseL, Thuja. 

Apis met. — For some reason, notwithstanding the abundant 
clinical records, this remedy is not mentioned in our text- 
books. A comparison of its general pathogenesis with the 
cardinal symptoms of the disease shows an almost complete 



TREATMENT OF GONORRHOEA 249 

parallelism, particularly in the early part of the second stage, 
and latter portion of the first. There is scanty urination, and 
puffy (Edematous swelling of the parts, but above all the 
peculiar biting-stinging pain. The discharge is thin, but 
distinctly purulent, and when the remedy is given at the 
proper time the disease may be aborted, or its later phe- 
nomena materially modified. For some twenty years I have 
been in the habit of giving this remedy in all cases of gonor- 
rhoea in the suitable stage, and have rarely failed to secure 
the desired result. 

Arsenicum. — This remedy is to be selected when the heat, 
swelling, and inflammation is intense; the prepuce is swollen 
and cedematous, and of a dark or livid color; the discharge is 
scanty, thin, and of bad quality; the urine is scanty, and seems 
to be boiling hot, or even like melted metal; the sufferings are 
relieved from warmth, and renewed from the slightest contact 
with cold. There is a form of gonorrhoea, the g. sicca, 
described by some writers, in which there is no discharge; I 
have never seen such a case, but admitting the possibility 
Arsenic would symptomatically be the remedy. It is to be 
thought of in all cases where the turgescence is so great that 
gangrene seems threatened, and where there is the character- 
istic i\rsenic fever; hot, dry skin, thirst for small quantities, 
and bodily restlessness. 

Belladonna. — In some respects the indications for this remedy 
resemble Arsenic, but on closer examination they are very 
different. There is the same intensity of the process, but of 
a different character. The swelling and inflammation are 
intense; sensitiveness to touch, scanty discharge but thick 
and yellow streaked with blood. The sympathetic fever is 
characteristic, the familiar symptoms, and the aggravations 
coming on suddenly. There is none of the adynamic character 
observed under Arsenic, the whole process being decidedly 
sthenic. Gangrene may occur, but it follows extreme stasis, 
the scarlet redness changing to a dark purple, and then black. 
In the Arsenic case the color is never bright red, oftener a 
brown, or livid hue. 



250 



ELEMENTS OF SURGICAL PATHOLOGY 



Cannabis saliva. — This remedy has enjoyed a reputation in 
the treatment of gonorrhoea that, in my experience, it is far from 
meriting. I have never cured a case with it, although given 
in all attenuations, and in very many cases; in fact it has never 
seemed to have any influence whatever. The symptoms 
given by Lilienthal ( T/ieraJ>.) are as follows: The urethra 
feels sore as if drawn up into knots, prepuce greatly swollen ' 
and sensitive to the touch; ulcerative soreness of the urethra 
on touching it; smarting and burning during and after micturi- 
tion; constant urging with difficult urination; dark redness of 
the gians and prepuce; priapism, with free mucoid discharge. 
In women, where there is cutting during micturition between 
the labia, violent sexual desire, with swelling of the vagina,, 
the orifice of the urethra closed with muco-pus. Urine is 
voided in a spray. These symptoms are nothing characteristic, 
but our author tells us the remedy is chiefly indicated " in the ' 
premonitory stage, when the discharge is yet thin." 

Cantharis. — This remedy is of great value where the reten- 
tion of urine is extreme, strangury, the urine coming in drops 
mixed with blood; violent erections, chordee, more or less 
accompanied by sexual desire. Between these paroxysms, 
the symptoms are somewmat characteristic; the pain is a sore 
smarting, as though the urethra were excoriated; the dis- 
charge is thin, watery, and ichorous. Cold applications relieve 
the smarting, and reduce the priapism. 

Gelsemium. — This remedy is used empirically, particularly 
in some of the southern states. Given on indications its patho- 
genesis is somewhat scanty; pain is severe, and discharge 
scant; its greatest field of usefulness is in cases of suppression, 
followed by rheumatism or orchitis. 

Petroselintnn. — The ordinary symptoms of the second stage> 
but the biting-stinging is changed to the most intense itching, 
deep in the urethra, so much so that the patient is tempted to 
introduce some rough substance for relief. 

Stigmata maidis, is a remedy that has a most enthusiastic 
following just now; if half that is told of it is true, it is almost 
a specific for gonorrhoea in the acute stage. 



GONORRHOEA 



251 



Thuja. — Occasionally, late in the second stage, the acute 
symptoms having mostly subsided, and the discharge become 
serous, there is a sensation of a drop rolling along the urethra, 
after or between the acts of micturition; nothing appears at 
the meatus, however, the sensation being purely subjective. 
Thuja at this time seems to have a highly beneficial effect on 
the third stage, shortening it materially. 

3. Chronic Inflammatory Stage. — This stage commences 
with a gradual subsidence of the symptoms of acute inflam- 
mation, diminished pain, heat, swelling; natural micturition, or 
but slight irritation attending the act, and usually a lessening 
of the discharge; there are cases, however, in which the dis- 
charge remains profuse, distinctly purulent, while all other 
acute symptoms disappear. The ordinary duration of this 
stage may consume two weeks, the discharge diminishing 
from day to day, becoming less and less purulent, more serous, 
and- ultimately ceasing entirely, leaving the parts, as far as 
ordinary inspection will determine, pretty much as they were 
originally. On more careful and minute inspection, there will 
be found notable change in the tissues, due to the plastic 
infiltration they have been subjected to; they will be thicker, 
firmer, and with evidences of specific inflammation which will 
very slowly and imperfectly disappear; in some cases, it is 
probable, some traces of the disease may continue during life. 

Treatment, in general, will be a simple continuation of the 
remedy used in the second stage. Occasionally some other 
remedy will be needed, usually one of the following. 

Hydrastis, when the discharge continues profuse, the other 
symptoms of acute inflammation having passed away. This 
remedy, by the way, is a very useful one in cases of fre- 
quently repeated gonorrhoea, in which the acute symptoms 
are always modified.- 

Pulsatilla, where the discharge remains quite profuse, is 
yellow or greenish, and there is smarting in the urethra 
relieved by cold applications. 

Alumina, there is no pain, soreness, or any difficulty in 
urinating, but the discharge loses its purulent character, 
becoming albuminous and stringy. 



252 



ELEMENTS OP SURGICAL PATHOLOGY 



Sulphur, has a formication in the urethra, sometimes with 
a scanty, intermittent, watery discharge. 

In probably the majority of cases of gonorrhoea, taking all 
kinds together, the third stage has a very imperfect termina- 
tion, if indeed it may be said to have any termination at all. 
It degenerates into a condition of Gleet, which is character- 
ized by a slight discharge, hardly noticeable, in the majority 
of instances, but which causes much annoyance. This may 
continue for months, or even years. The discharge may be 
a mere drop or two in twenty-four hours, sometimes not 
appearing as a fluid, but as a dried film, closing the meatus. 
In itself it has little significance, and causes no inconvenience, 
but it is associated with a serious lesion deeper in the parts, 
viz., a stricture. Occasion will be had to return to this later, 
at this time it is sufficient to call attention to the fact. 

Treatment of gleet is very unsatisfactory. Recognizing 
the fact that gleet is a symptom of stricture, and stricture, as 
a sequence to gonorrhoea being almost always cicatricial or 
its equivalent, fibrinous infiltration, Silicea would first occur to 
one who has had much experience in surgical practice. In 
fact it takes first rank, from all considerations. Arg'entum 
nit. occupies second place, and perhaps Sulph. would be 
useful in certain cases. One of these remedies is certainly 
indicated, in every case. The popular method of treatment 
is the use of solid steel bougies, which have a certain applica- 
tion from the occasional cure of the stricture. The great 
danger is, that the dilatation of the urethra is sometimes car- 
ried too far, and the function of the organ impaired corre- 
spondingly. If the practitioner can guard himself against this 
over dilatation, certainly the bougie is a valuable instrument. 

Complications and Sequelae. — The majority of the com- 
plications of gonorrhoea, are purely accidental in character, or 
due to the intensity of the morbid action, not its specificity 
Thus we find in cases of great severity, lymphangitis, extend- 
ing to the inguinal glands as " bubo." Phimosis, when the 
prepuce is long, from swelling and infiltration; para-phimosis, 
under opposite conditions, either from swelling of the prepuce, 



COMPLICATIONS OF GONORRHCKA 253 

or of the glans; balanitis* or inflammation of the glans; pros- 
tatitis, acute or chronic: haemorrhage, from rupture of small 
vessels in the urethra; ulceration of the urethra, from general 
causes; laceration of the urethra, from forcibly straightening 
the penis in chordcc,i\ practice of the ignorant \ fracture of the 
corpus cavernosum. from the same causes, besides others of a 
similar character. There are other complications and sequela: 
that have a different complexion, and call for more extended 
notice. 

Herpes Preputialis is a not uncommon complication, but 
from its association with gonorrhoea presents some peculiar 
features. It commences, like all herpetic eruptions, with the 
appearance of red spots, on the internal or external surface 
of the prepuce, soon, in many cases, extending to the glans, 
on which appear minute vesicles, in groups of from two to 
four, which break, in a day or two, but then lose, to some 
extent, the ordinary characters of herpes. The discharge 
soon becomes purulent, the red spots coalesce, the broken vesi- 
cles leave patches of erosion that have a tendency to run 
together, and in some cases even become transformed into 
ulcers. In some cases the ulceration is very extensive, which 
from the associated local disturbance makes recovery very 
tedious, and may even result in gangrene and sloughing. 
There are many cases that bear such a strong resemblance to 
syphilitic chancre that serious mischief has resulted from the 
energetic treatment to which some heroic routinists are partial. 
I have seen most formidable cases, cases in which recovery 
was only secured with some lasting deformity- One case was 
sent to my clinic, some years ago, the letter of introduction 
stating it to be a " typical one of syphilis." The treatment 
had been Mercury, to the extent of salivation, and calomel 
topically; the case looked like one of chancroidal phagedena, 
and it was only the remarkably clear history that enabled a 
diagnosis to be made. Such aggravated cases are very diffi- 
cult to treat, and call for the utmost patience and confidence 
on the part of the sufferer. Simple Hcrfes, which preserves 
the typical characters, is easily subdued, but these complicated 



254 ELEMENTS OF SURGICAL PATHOLOGY 

cases, even when not maltreated, as so many are, probably do 
better on Rhus or Sulphur than any single remedy. Arsenic 
would be indicated when gangrenous symptoms arose. I 
have found Calendula, topically or otherwise, of benefit when 
the morbid action was arrested, and the ulcers were slow to 
heal. 

Orchitis and Epididymitis, inflammation of the testicle and 
epididymus respectively, are treated clinically as the same 
affection, and indeed the one is simply a further development 
of the other. The symptoms are quite similar, and while for 
therapeutic purposes it may not be essential to establish a 
perfect differentiation, yet for purposes of prognosis it is very 
important to do so. There are a variety of opinions as to the 
manner in which the epididymus or testicle becomes implicated 
in the gonorrhoeal inflammation, the most plausible, and the 
one most in harmony with the theory of the specific nature of 
the malady, being that the inflammation extends "along the 
ejaculatory ducts and spermatic canals" to the epididymus, 
and thence, at times to the testicle. In cases of traumatism, 
of course the injury is the direct cause, and while the semei- 
ology may be very similar, the pathology, and the conse- 
quences, I think, are very different. It goes without saying, 
that inflammation of these structures may occur from a variety 
of causes; cold, direct injury, and excessive or violent sexual 
commerce, furnishing many cases. The majority of these 
affections, however, have a direct causative relation to gonor- 
rhoea. The first symptoms usually appear about the fifth or 
sixth week, about the time that the second stage approaches 
its close. The patient will first complain of some sensitiveness 
and feeling of dragging in the inguinal region, usually on the 
left side — with perhaps some fullness at the upper part of the 
cord, just after it passes out of the inguinal canal. On seizing 
the cord between the finger and thumb, and gently rolling it, 
the vas deferens will be found swollen, sometimes very little 
if any, but usually two or three times its ordinary dimensions, 
and sensitive; there may not be a positive pain, but that 
peculiar faint, nauseous sensation felt when the testicle is 



COXOURHCEA 



255 



Compressed. Soon the scrotum commences to swell, and 
becomes retracted, assuming a dark, somewhat smooth appear- 
ance, occasionally a bright red — and hot to the hand; sensitive- 
ness increasing with the augmentation in size, until finally, the 
pain is constant, whether the parts are touched or not, the 
weight gives a sensation of dragging, there is feverishness, 
and later the recumbent position is the only one that can be 
borne at all. The swelling may be anything from an orange 
to a large cocoanut. The pain and dragging are so severe 
when standing or sitting, and jars, or contact increase them 
to such a degree, that lying down, with the scrotum suspended 
in some sort of sling becomes a necessity. Even when lying 
down, the trunk is bent forward, and the knees drawn up to 
diminish the tension, and to avoid contact or compression the 
knees are kept widely separated. Laughing, coughing, the 
shaking of the bed, or any movement of the body cause so 
much pain, that the patient dreads the approach of anyone, or 
their moving about the room. In most of the cases I have 
seen the scrotum becomes more or less covered by a vesicular 
eruption, sometimes smarting to an extent that seriously adds 
to the discomfort. The duration of an attack is uncertain; I 
have known cases to recover in a week, and others require 
two or three months; perhaps the average will be, from first 
to last, three weeks. 

There may be a question, particularly in traumatic cases, 
"whether it is a hematocele, or hernia, but the diagnosis is 
generally sufficiently easy from a consideration of the extreme 
and peculiar pain, and the enlarged epididymus. Furthermore, 
hematocele and hernia, are both developed soon after (im- 
mediately in fact) the reception of injury, whereas the epididy- 
mitis or orchitis come on more slowly, and are much more 
tardy in reaching full development. 

A question as to termination, as related to cause more par- 
ticularly, will claim close attention, and I think the doctrine of 
the specificity of gonorrhoea here receives much support. 
The case being purely traumatic, the result will be as in non- 
specific inflammation in general; that is, the intensity of the 



256 ELEMENTS OF SURGICAL PATHOLOGY 

process determines the result. In ordinary cases resolution 
leaves the parts substantially normal from the products , of 
the process being absorbed. In higher grades of intensity, 
suppuration* may ensue, and if the part escapes complete 
destruction, cicatricial repair endangers its integrity from 
atrophy. The same results are observed in the non-specific 
forms, non-traumatic in character, perhaps the danger of sup- 
puration is much less. In the gonorrhoeal forms, however, a 
much different history is observed. Complete resolution may 
be said never to occur, and suppuration with extreme rarity. 
The most common termination is in a slow retrocession, with a 
permanent enlargement of the globus minor, feeling like a hard 
cartilaginous button. In other cases the ducts are permanently 
closed, the accumulation of seminal fluids forming a '-sper- 
matic cyst." In still others, when the testicle is involved, there 
will be an imperfect subsidence of the swelling, a sarcocele 
remaining, which on proper provocation may readily pass into 
some distinct form of tumor. In a. few instances I have seen 
atrophy of the testicle supervene, in one case it almost com- 
pletely disappeared. This difference in results must neces- 
sarily be due to differences in the process; one case, the idio- 
pathic, represents the typical course of inflammatory action; 
the other represents a formative or constructive action, char- 
acteristic of specific disease. It would not be true to refer all 
cases of sarcocele to gonorrhoeal orchitis; but it is true that 
gonorrhoeal swelled testicle determines a permanent change in 
the organ that peculiarly predisposes it to extensive tissue- 
change on slight provocation. 

Treatment must be medicinal and adjuvant. The latter 
begins and ends, I think, in providing proper support for the 
organ, such as a sling or suspensory bandage and does not 
include any compression, which I have come to consider a 
serious error, i. <?., serious in its results. I can give no reason 
for this opinion beyond my clinical experience, which would 
seem to be somewhat different from that of practitioners in 
other schools of therapeutics. The remedies are to be selected 
as though there were no question of specificity, solely on the 



GONORRHOEA!, RHEUMATISM 



257 



indications, but do not, in my experience, include a very large 
number. 

Belladonna is called for when the pain, heat, and swelling' 
are acute, the surface smooth and red, sensitive to the least 
touch, or jar of the floor; fever high, of the synochal type, and 
the general symptoms so quickly recognized. 

Phytolacca takes first rank when the acute symptoms abate 
but the swelling is tardy in going down, or shows no disposi- 
tion to abate. 

Rhus tax. is indicated in cases with much vesicular erup- 
tion, dark redness of the part, constantly changing the posi- 
tion, and the fever has a tendency to assume typhoid char- 
acters. 

Silicca has done me good service in one or two cases in 
which the former remedy produced no effect, the testicle 
remaining swollen after all acute symptoms had disappeared. 

Conium has likewise been useful, particularly where the 
weight was extreme, as from a stone. 

Aurum fol. is indicated where the course of the disease is 
chronic, and the peculiar suicidal melancholy obtains. 

Iodine has seemed to arrest threatened atrophy, in one case 
even securing a normal development of what seemed to be a 
hopelessly lost gland. 

Pulsatilla has a reputation of particular relation to orchitis, 
but has never given me any satisfaction. The indications for 
its use, as far as objectivity are concerned, are not marked. 

Arnica takes the first rank in traumatic cases, particularly 
from contusions, unless suppuration threatens, when remedies 
will be called for as in suppuration in general. When pus has 
once formed, it must be evacuated precisely as for abscess 
elsewhere. 

Gonorrhceal Rheumatism. — In an earlier paragraph I had 
occasion to refer to the article on gonorrhoea by L. W. White, 
M. D. {Int. Cycl. of Surgery, 11., 325), calling attention to his 
views as to the specific character of the disease. When he 
reaches rheumatism (p. 346), he uses the following remark- 
able language: " There is no discoverable connection between 

S 



258 ELEMENTS OF SURGICAL PATHOLOGY 

this form of rheumatism and any tendency, hereditary or 
acquired, to rheumatic disease; my own experience has amply 
convinced me of this fact. Besides, as will be seen, there are 
broad distinctions between this disease and ordinary rheuma- 
tism." This is remarkable language from a man who a few 
pages back denied that gonorrhoea had any peculiar and 
definite pathology, which it should have to entitle it to classifica- 
tion among the specific diseases! He attempts to account for 
it on the theory of septic infection, but it would be a difficult 
matter to show its semeiologic relationship to septicaemia from 
other sources. The peculiarities are, that the symptoms only 
appear during the height of the disease, when the purulent 
discharge is profuse; it attacks men, in preference to women; 
the trouble is alway in a joint, sometimes one, at others several; 
there is great and rapid synovial accumulation, and no consti- 
tutional symptoms as a rule. The case is more one of acute 
arthritis, than rheumatism. The symptoms usually arise 
suddenly, rapidly reach their maximum, the joint being hot, 
swollen and exquisitely sensitive, and ordinarily rapidly sub- 
sides. If such a case were seen without accompanying gonor- 
rhoea, it would attract attention from the speedy establishment, 
rapid development, and equally rapid decline. While the rule 
is a speedy subsidence of the acute symptoms, yet there is a 
marked tendency to hydrarthrosis, which may continue for a 
long time. 

Our author, as one -proof (!) of its difference from the 
ordinary rheumatism says: "Anti-rheumatic remedies are 
unavailing." Now, for our part, the reverse is true, for the 
" anti-rheumatic remedies " are positively, promptly, cura- 
tive. Rhus, Bry., and Arsenic will rarely disappoint, particu- 
larly if there is no prejudice against the 30th attenuation or 
even higher. 

Gonorrheal Ophthalmia and Conjunctivitis. — Of late 
years I have studiously avoided the treatment of ophthalmic 
cases of all kinds, having reached the conclusion that they are 
eminently "special" in character. I accordingly crave indul- 
gence for a liberal quotation from the article of Dr. White 



GONORRHOEA!, OPHTHALMIA 



259 



[local.) who gives a most admirable condensed account of 
this most formidable complication. I prefer a condensed 
account, as I wish to discourage the general practitioner from 
attempting to treat such cases, unless he is so situated that he 
cannot do otherwise. He says (p. 348) : " Associated with 
these joint troubles in many cases, or occasionally occurring 
as the only complication of a urethritis, there is an inflamma- 
tion of some of the structures of the eye, known as gonorrheal 
ophthalmia. The sclerotic coat, the iris, the oculo-palpebral 
conjunctiva are the tissues chiefly affected — the symptoms 
being those of a common iritis or conjunctivitis, attended with 
considerable aching pain, and accompanied by only a moder- 
ate amount of muco-purulent discharge. The usual remedies 
have a beneficial effect, but the disease tends to run a rather 
chronic course, and finally to subside spontaneously." It will 
be observed that this is not due to inoculation with the ure- 
thral discharge, a fact which must be emphasized by those 
who claim specific characters in gonorrhoea. 

''This complication should not be confused with the very 
different and much more serious condition of gonorrhoea! con- 
junctivitis, although they are often spoken of as identical. 
The latter trouble is the result always of direct inoculation, 
the pus being transferred by the finger or otherwise to the 
edge or inside surface of the lids. The symptoms commonly 
make their appearance within a few hours, and are at first 
like those of a simple catarrhal conjunctivitis. They increase, 
however, with almost incredible rapidity, so that an eye which 
twenty-four hours previously was entirely healthy, will be 
found with tense, swollen, ©edematous, bulging, erysipelatous- 
looking lids, from between the closely approximated edges of 
which a thick purulent secretion is oozing; on separating 
them the conjunctiva is found injected and chemosed, and 
bathed in pus. In a short time if the chemosis is not relieved, 
the supply of blood being cut off from the cornea, the latter 
ulcerates in one or more spots, or may become detached and 
fall out entirely, permitting a complete loss of the contents of 
the globe. The whole series of phenomena may occur within 

S 2 



260 



ELEMENTS OF SURGICAL PATHOLOGY 



three or four days, and not infrequently has occupied only 
half that time. The pus from such an inflammation is intensely 
contagious, irritates the cheeks over which it flows, and will, 
to a certainty, affect the sound eye, if any be allowed to come 
in contact with it. 

"It is of great importance, from the very onset of the 
disease, it should be distinguished from the mild, self-curable 
affection which we have described. The main points of dif- 
ference are contained in the following table: 



"GoXORRHCEAL CONJUNCTIVITIS. 

Produced by contagion only. 



Occurs once in seven hundred or 
eight hundred cases of gonor- 
rhoea. 

May be derived from a second per- 
son, by pus inoculation. 

Involves one eye primarily. 

Remains limited to eye originally 
affected, unless the other is ac- 
cidentally inoculated. 

Symptoms affect the conjunctiva 
from the start. 

Symptoms of greatest gravity and 

urgency. 
No association with subsequent 

gonorrhoea. 
No relation to joint trouble, or other 

rheumatic affections. 

Tendency to rapid destruction of 

tissue involved. 
Treatment very useful; should be 

prompt and energetic." 



" GONORRHEAL OPHTHALMIA. 

Produced probably by septicemic 
infection. (?) Has no relation to 
direct contagion. 

Occurs once in fiftv or sixty cases. 



Can only occur in a person having 

urethri is. 
Involves both eyes usually. 
Frequently passes from one eye to 

the other. 

Symptoms affect the fibrinous tis- 
sues, the sclerotic coat and the 
-iris. 
Symptoms mild, sub-acute. 

Frequently returns with each later 

attack of gonorrhoea. 
Most commonly found to coexist 

with some other form of gonor- 

rhceal rheumatism. 
Tendency to final but slow cure. 

Treatment not very effective; should 
be mild and expectant." 



The above brief account is as much as can be useful in a 
book not concerned with ophthalmic medicine; the fact of 
malignancy, and rapid destruction of the tissues needs empha- 
sizing, and cannot be dwelt upon too strongly. The loss of 
an hour in the commencement may easily doom the eye to 
destruction. 



GONORRHCEAL OPHTHALMIA 261 

Treatment must consequently be prompt, vigorous and 
thorough. The first item is absolute cleanliness, and protec- 
tion of the sound eye. These two items are placed together 
as one, because careless cleansing may inoculate the sound 
eve. The lids being tightly closed ordinary ablution will be 
ineffective; they must be gently separated, and the accumu- 
lated pus washed out, by means of a small syringe made for 
the purpose. Preliminary to this the sound eye should be 
closed, to guard against accident, either by a strip of adhesive 
plaster, or something equally efficacious. This cleansing 
should be done at intervals of twenty minutes, or half an hour, 
in severe cases perhaps oftener, the utmost gentleness being 
used, to avoid all unnecessary irritation. The syringe should 
be thoroughly cleansed immediately after using, and all cloths, 
cotton, sponges, pieces of muslin, or other articles that have 
come in contact with the discharge, must be burnt. This last 
should be scrupulously attended to; all such material must be 
burnt at once, not laid aside for future attention, or thrown into 
vaults, ash-pile, or buried. Fire is the only treatment. As to 
treatment by remedies, Drs. Allen and Norton (Ofl/?t/?. 
Therafi., p. 181), say: " Argentum nit. This is the remedy, 
-par excellence for all forms of purulent ophthalmia. We have 
witnessed the most intense chemosis with strangulated vessels, 
most profuse purulent discharge and commencing haziness of 
cornea with a tendency to slough, subside rapidly under this 
remedy, internally administered. We believe there is no need 
of cauterization; but that all the beneficial results may be 
obtained by its use in the potencies. The subjective symptoms 
are almost none. Their very absence, with the profuse puru- 
lent discharge and swollen lids, swollen from being distended 
by a collection of pus in the eye, or from swelling of the sub- 
conjunctival tissues and not from infiltration of the connective 
tissues of the lids themselves (as in Rhus or Apis) indicates 
the drug. 

" By its employment as a cauterizing agent, as used by the 
old school, there is no doubt that many cases of purulent 
conjunctivitis are cured, though with risk to the cornea, as is 



262 ELEMENTS OF SURGICAL PATHOLOGY 

attested by the results of this treatment. These sad results, 
viz., perforation of cornea, dense leucoma, etc., we claim are, 
to a great extent, averted by the use of the remedy in the 
potencies, either internally alone or both internally and 
externally. We are in the habit of using the thirtieth potency 
internally, and, at the same time, a solution of five or ten 
grains to two drams of water of the first, third, or thirtieth 
dilution as an external application, all the time taking care to 
ensure cleanliness; and we have yet to see the first case go 
on to destruction of the cornea." 

Other remedies may be needed, for some modification of 
the malady, such as Arsenic, or Rhus, or Merc, yet few cases 
will resist the action of the Argentum. While so much stress 
has been laid on protection of the sound eye, it would seem 
unnecessary to call attention to protection of the eyes of the 
nurse, physician, and others having to do with the patient. 
The most extreme caution must be exercised in thoroughly 
cleansing the hands, and avoiding contact with any article of 
clothing or dressing, or appliances of all kinds that may have 
had contact with the pus. 

Stricture. — Unquestionably one of the most serious results 
of gonorhoea, is stricture of the urethra. The subject is one 
of such magnitude, and of such importance from therapeutic 
considerations, that a chapter could easily be devoted to its 
consideration. As a work on pathology, with only passing 
reference to therapeutics, the space disposable compels brev- 
itv. The word stricture means a constriction or narrowing 
of the diameter of a canal; in practice it means something 
more than this, viz., a loss of expulsive power. The urine is 
expelled by an association of forces all of which, and in due 
proportion, are essential to the perfect performance of the act; 
the failure or insufficiency of any one of them, must cause at 
least a functional impairment, and in most cases even more 
than this. These forces are the contraction of the abdominal 
muscles, of the muscular fibres of the bladder, and of those of 
the urethra. The urethral fibres, and the perineal muscles 
concerned in the act of urination must be relaxed in the begin- 



URETHRAL STRICTURE 263 

ning contracting again at the close, to empty the urethra. We 
learn from this that the urethra does not play a purely passive 
part in micturition: it is an active participant, and one of some 
considerable potency. To convert it into a simple tube, a 
waste pipe, will either render the whole act of urination 
imperfect, some urine being retained in the urethra, or flowing 
back into the bladder — or its failure will devolve additional 
effort in the other forces, which not only exposes them to 
injuiy, but even then leaves urine in the urethra that cannot 
be expelled by any force. Thus we find a stricture, patho- 
logically considered, is a loss of muscularity, as well as a 
diminution of calibre; in fact the mere reduction of calibre is 
a comparatively unimportant consideration. The stricture 
has its origin in a plastic infiltration, or rather organization, 
in the mucous and sub-mucoid tissues, causing a narrowing of 
the lumen of the canal; or in an ulcer or erosion, which heal- 
ing by cicatrization, causes a contraction and thickening at 
the same time. Like all such processes, wherever found, 
once commenced they remain as permanent defects, and the 
peculiar property of contraction induces a constantly diminish- 
ing capacity of the urethra. They induce, also, an irritation 
amounting to a sub-acute inflammation, which gives rise to 
the gleetv discharge before alluded to, and also causes a 
spasmodic irritability in the muscular fibres in the neighbor- 
hood. The urine is now expelled with great difficulty, partly 
from the narrowing of the canal and the increased friction 
occasioned thereby, and partly by the loss of the peristaltic 
action of the tube itself. The difficulties increase, as time 
goes on, the stricture becoming, as the saying is, tighter and 
tighter, until in extreme cases the opening is so minute that it 
is only with the most extreme and painful effort that the 
bladder can be emptied at all. This constant straining often 
induces abdominal hernia, or even aneurysm, so that the conse- 
quences are not by any means confined to a simple impedi- 
ment to urination. In the commencement, the patient will 
complain of delay in starting the stream of urine, feebleness of 
impulse, and dribbling of urine for some little time after the 



264 ELEMENTS OF SURGICAL PATHOLOGY 

act. Later the stream will assume a variety of abnormal 
shapes, spiral, fan-shaped and the like, and at times, particu- 
larly on exposure to cold, to over exertion, or from some indis- 
cretion in eating or drinking (particularly the use of alcoholic 
stimulants), there will be strangury or retention of urine 
from spasmodic contraction of the irritable muscular fibres. In 
the natural history of a case, the stricture will finally become 
so tight that it is almost impossible to pass water at all, and 
then only after numerous painful efforts, with severe straining 
sometimes for hours. The nights are sleepless, from the fre- 
quent ineffectual urging to urinate, and soon the general 
health becomes impaired. The troubles do not cease here, 
unfortunately. The retained urine in the urethra undergoes 
decomposition, the constant irritation and inflammation induces 
other deposits similar to the original, and additional strictures 
may form, which go through the same history of development, 
and add to the existing difficulties. In very extreme cases, 
the urine is retained, threatening the kidneys [choking them) 
and pvo- or hydro-nephrosis results, with death as the almost 
inevitable sequelae. In some cases again, abscess may occur 
deep in the urinary canal, and pointing on the perineum, or 
elsewhere, establish a urinary fistula which renders life almost 
unendurable. Such is the natural history of stricture, and it 
needs nothing more to indicate the symptomatic value and 
significance of gleet, so lightly regarded by too many practi- 
tioners. 

Strictures are readily divided into two general kinds, 
those of large, and those of small calibre. The latter always 
begin as the former; they are a simple development of the 
former. The mere existence of gleet is a legitimate cause for 
suspicion, and the stricture must be sought for. The olivary 
sound [sonds a bottle, of Otis) are the only instruments, known 
to me that are at all satisfactory for diagnostic purposes. 
They are furnished in sets, and not only show at once the exist- 
ence of stricture, but its location, length, size and character, 
i. e., whether hard or soft. Having determined these facts, 
some intelligent conception can be formed of the indications for 
treatment. 



CHANCROID 265 

Treatment is almost from the necessities of the case, 
instrumental. In the commencement, when gleet is first 
observed, the remedies mentioned under that head will often 
prove curative. Later, however, when the stricture is well 
developed, remedies alone, I am forced to conclude, are utterly 
inoperative. Conjoined with other treatment, and only then, I 
have found Silicea the only remedy that has the slighest 
influence; for the spasmodic closure of the urethra, JVux vom. 
or Cantli. are useful, but the organic stricture must come 
within the domain of the surgeon solely. The plan of this 
work does not contemplate more than a reference to purely 
mechanical therapeutics, therefore the subject must be dis- 
missed with the mere list of procedures, in the order in which 
I have found them valuable. Galvanism, dilatation, internal 
urethrotome, external urethrotomy, and divulsion, which last 
I include in deference to custom alone, esteeming it to be not 
onlv valueless, but barbarous and hurtful. 

CHANCROID. 

In former times svphilis was supposed to exist in two forms, 
the primary lesion, or the ulcer, indicating the form; soft 
chancre, as it \vas~ called, beino- recognized as a non-infectinir 
sore, that is the morbid action ceased with its disappearance; 
the hard or Hunterian cliancre was only the commencement of 
later and more serious trouble. As time went on, and facili- 
ties for the minute study of the tissue-changes became per- 
fected, the conviction gained ground that the conditions were 
dissimilar, had no relation to each other apart from a common 
venereal origin, and that the contagious principle was conse- 
quent!}' totally different. The present teaching, with a few 
notable exceptions, is that the diseases represented by these 
two forms of ulceration, are as distinct as any two totally 
unlike morbid actions can be. This doctrine is known as the 
dualistic; that which assumes an identity in the processes, 
modified by accidental circumstances, is known as the unicistic* 
There are a number of excellent authorities on the unicistic 
side of the controversy, but the larger number of teachers, 



2 66 ELEMENTS OF SURGICAL PATHOLOGY 

writers, practitioners with enlarged opportunities for compari- 
son, are ranged on the opposite side. I shall attempt no argu- 
ment, the subject being worn somewhat threadbare, believing 
a plain statement of the symptomological differences will fully 
sustain the position taken. At the same time, I am compelled 
to say, the differences are often more pronounced in print than 
in actual practice, so many circumstances combining to obscure 
and complicate the characteristics. The sources of error in 
diagnosis, are many, and formidable; insufficient or untrust- 
worthy [history of the case; changes in the objectivity from 
accidental complications, as inflammation; improper treatment 
adding drug sj^mptoms to those of disease; renewed exposure 
to venereal contagion, and a mixture of the two forms of dis- 
ease resulting; some constitutional dyscrasia or diathesis, and 
many others, often operate to produce a state of facts that 
readily mislead even those who may be considered of first-class 
attainments. Nevertheless, there are certain essential symp- 
toms, in each form of disease, rarely so completely obscured 
that they escape recognition, and these I shall endeavor to 
present in a manner that will lix them in the memory, and at 
the same time emphasize the systematic differences. 

The ancient soft chancre, or -non-infecting sore," is now 
universally known as chancroid. The general characters are 
well given by Surgeon P. H. Batlhache, U. S. Marine Hos- 
pital Service {Report for 1875, P- J 62). He says: i; Chan- 
croid is a contagious, acute, local disease, not peculiar to the 
human race, the result of a local poison, introduced by actual 
contact of a denuded (or possibly of an epithelial) surface 
with the purulent secretion of a venereal soft chancre or viru- 
lent bubo — the most common means of contagion being 
through sexual intercourse. Chancroid first manifests itself 
by one or more lesions at the point of contact, which lesions 
have a tendency to destructive ulceration. A pustule, revealing 
itself within twenty-four or forty-eight hours after exposure, 
and rapidly developing into a soft chancre without any period 
of incubation, characterizes the inception of the disease, which 
mav or may not be followed by sympathetic or virulent bubo. 



CHANCROID 267 

The purulent secretions of soft chancres and virulent buboes, 
are indefinitely auto-inoculable ; but uncomplicated chan- 
croidal lesions are never followed by constitutional (specific) 
disease." 

The first distinguishing feature of chancroid, is the absence 
of any incubation, some indication of infection appearing 
almost immediately upon exposure, certainly within a very 
few hours. The initial lesion is oftener found on the genitals, 
inasmuch as the disease is very venereal, but may be found 
on any part of the body, in any tissue, pathological as well as 
physiological. The sole condition of infection, after exposure, 
is that the virus shall come in contact with a surface capable 
of absorption, either from its physiological character (as a 
mucous surface), or abrasion of an ordinary cuticular one. 
Prolonged contact with the pus, however, as might occur 
where it was contained in a fold of the skin, particularly if 
the surfaces were subjected to friction on each other, w r ould 
determine absorption through the skin. Thus the commoner 
locality will be the preputial fraenum, the corona glandis, 
almost any part of the genital apparatus of women, or the 
folds in the groin, nates, or elsewhere in that region. The 
heat and friction combined, when the lodgment is cuticular, 
will soon produce erosion, and thus the conditions of absorp- 
tion are created. The only equivalent for incubation, there- 
fore, is the time required for absorption; immediately upon 
this occurrence symptoms are produced. It is conceivable 
that in a person of filthy habits, a drop of chancroidal pus 
might remain in contact with a thick cuticular surface suffi- 
ciently long to give an appearance of incubation, and possibly 
render a diagnosis uncertain. Hence the part affected, and 
the character of the individual might assume importance as 
diagnostic factors. 

Soon after absorption, almost immediately, there will appear 
a red spot, rapidly developing into a pustule, surrounded by 
an inflamed areola of varying size — sometimes there will be 
two or even more pustules arising on the same spot, or close 
together. The areola and base are not indurated, in the sense 



2 68 ELEMENTS OF SURGICAL PATHOLOGY 

of syphilitic induration, but firm, shading off imperceptibly 
into the surrounding parts, like any inflammatory action. 
There is considerable pain, and the whole process is of a 
character to call attention to it, so that it cannot pass un- 
noticed. A distinguishing feature can now be observed: The 
pus is auto-inoculable, that is wherever deposited, infection 
follows. The body may be inoculated in any part, and anv 
number of times, and chancroidal pustules will follow. This 
is not so in syphilis. 

Shortly the pustule will break, revealing an ulcer, that as 
compared to syphilis, has prominent characteristics. The 
edges are sharp-cut, the outline irregular; frequently the 
edges are undermined, sometimes inverted, never (or rarely) 
elevated, the floor is uneven, " worm-eaten," dull color, or 
covered with a yellowish, or brown slough. There is con- 
siderable pain, profuse discharge of pus, a wide areola, and 
rapid development, with slow repair. The characteristic 
features are, first the auto-inoculability of the discharge, and 
second the destructive character of the process, as shown by 
microscopic examination of the product. The pus is filled 
with detritus, and there is no sign of construction discoverable. 
The inocubility has the effect to produce new pustules and 
ulcers, wherever the pus may lodge, and be retained, thus 
giving a succession of ulcerations, of differing ages, which is 
something so unique and characteristic that when satisfactorily 
established the fact alone must be considered conclusive evi- 
dence. The ulcer easily takes on gangrenous characters, and 
may produce the most extensive destruction of tissue; I have 
seen such an ulcer involving the perineum, one labium, most 
of the mons veneris, and extending over the abdomen half 
way to the umbilicus. Such an extensive loss of substance is, 
of course, only observed in exceptional cases; in those of un- 
cleanly habits there may be no limit to size or number of 
ulcerations; in those more careful in their habits, and who are 
warned of the consequences of neglect, subsequent ulcers may 
not occur. Under all circumstances, the cicatrix is a promi- 
nent one, usually somewhat depressed, white, and of the gen- 



CHANCROID 269 

era! characters of the vaccination scar. There may be a cer- 
tain amount of induration accompanying the ulcer, but it will 
be such as accompanies inflammation in general. 

The features that may be considered pathognomonic of 
chancroid, can now be tabulated, and when compared with 
those of syphilis, will be found as different as two unlike 
things can well be. For purposes of ready comparison this 
tabulation will be deferred until Syphilis has been described. 

Bubo, or enlargement of the inguinal, or other glands, is a 
common occurrence, but not at all constant. When it occurs 
the swelling is notably inflammatory, painful, suppurating, and 
acute as a rule. Ordinarily but a single gland is affected, 
rarely more than two. The discharge has the same character 
as the pus from the pustule and ulcer, viz., auto-inoculability. 
In some cases, for reasons not understood, it occasionally 
happens that a discharging bubo fails to heal, and may con- 
tinue for an indefinite time, even a year or more. 

There are some other features to be considered, some of 
which are not in harmony with the specific theory of the dis- 
ease, and in so far may be esteemed conclusive proof as to its 
being non-syphiiitic. The disease is never transmitted by 
heredity, nor any disposition to it. As far as known there 
are no conditions of body that will prevent contagion if the 
conditions are favorable. It is not prophylactic, as one attack 
does not in any way protect the individual from subsequent 
ones; indeed renewed infection may occur indefinitely during 
the existence of one outbreak. The effects are purely local, 
there being no symptoms of a disturbance of health, in any 
constant form at least, during the attack, such intercurrent 
symptoms as may arise being of a purely general character, 
not in any way, cause, progress, or decline — being influenced 
by the chancroidal disease. There may be, it is true, some 
irritative fever, but nothing different from what might arise 
from any local affection of similar intensity. The sole indica- 
tions of specificity, are that the pustule and ulcer always fol- 
low inoculation with the pus, that pus from no other source 
will have similar effects, and that no other agent than the 
chancroidal pus will develop the chancroidal disease. 



270 



ELEMENTS OF SURGICAL PATHOLOGY 



Chancroid seems to be a disease of the lower classes; it is 
more common, according to the authorities, in hospital prac- 
tice, than syphilis. The latter is eminently a disease of the 
higher classes, at least as far as the initial lesions are con- 
cerned. This is due to the inconspicuousness of the syphilitic 
chancre, in most cases not producing symptoms sufficiently 
obtrusive to attract the attention of those who are likely to 
consort with the abandoned creatures, of either sex, who 
would seek or permit sexual commerce during the existence 
of such a loathsome disease as chancroid. Among public 
women w 7 ho have not yet reached the lowest depths of deprav- 
ity, and are young in their ignoble calling, the occurrence of 
the slightest pimple or abrasion, or tenderness would prompt 
them to seek medical advice; so also w r ith their male compan- 
ions, who must necessarily be of the higher social scale. 
Among more degraded men and women, it must be a pro- 
nounced affection that w r ould compel them to seek medical 
aid. So it happens, that while the later stages of syphilis may 
be as common in one class of society as the other, yet the 
initial lesion is oftener seen among the better classes. 

What has been said above will have failed in its purpose if 
the fact of distinctive, unique, and pathognomonic features are 
not plainly apparent. In an uncomplicated case, a diagnosis 
is easy: the reverse is true under opposite conditions. Unfor- 
tunately there are many in the practice of medicine, who fail- 
ing to recognize these distinguishing features in their incipi- 
ency, create complications by injudicious treatment; the pos- 
sibility of a syphilitic contracting chancroid, or one with 
chancroid, incredible as it may appear — contracting syphilis, 
also gives us cases of so-called " mixed-chancre," in which 
some of the characters of both diseases appear. The use of 
astringents, and caustics, in the first place, may diminish a dis- 
charge, arrest a destructive action, and produce an induration 
that may resemble syphilis; in the second, the confusion is 
owing to the fact that both diseases do exist. The test is not 
a difficult one. Inoculation, of some other part of the body 
will surely reproduce the ulcer, if it is chancroid, and produce 



CHANCROID 



71 



no result if syphilitic. If doubt still exists, and the history is 
untrustworthy, the case had better be treated as syphilitic, 
even if the chancroidal disease is aggravated, as the syphilis 
is the element in the case to be feared. • 

Treatment. — A study of the conditions of contagion, as 
far the characters of the pus is concerned, has established the 
fact that the specific virility may be destroyed by various 
agents, notably heat and acids. Clinical testimony is abund- 
ant, and unquestionable, that the topic.il treatment of the 
ulcer by these agents, used judiciously, converts the venereal 
sore into an ordinary ulcer. There are unquestionably cases 
of chancroid that have been cured by remedies administered 
in the ordinary manner, but the time consumed, and the clin- 
ical history of such cases as have been fully reported leads 
one to question, after all, whether the treatment had any- 
thing to do with the results, when the diagnosis zvas correct; 
not a few cases, that have found their way into print, seem to 
have been herpes preputialis, and thus led to innumerable 
false deductions, repeated over and over again in our text- 
books. 

The first thing to be done, therefore, in all cases, is to 
convert the specific sore into a non-specific ulcer by cauteriza- 
tion. Nitrate of silver will not do this, as its action is super- 
ficial in the solid form; Nitric acid is to be prefered. Dipping 
a stick, such as a match, into the acid, and touching with it 
the ulcers, until all parts are evidently cauterized, is the best 
way. as thus the acid reaches all parts of the surface. The 
good effects are more promptly observed in the case of pus- 
tules, or ulcers in the earlier stages. The success of the pro- 
cess may be determined by inoculating the integument, £nd 
observing the effects; should a pustule form, the treatment 
has not been effectual, and must be repeated, the inoculation- 
pustule being freely cauterized at the same time. As soon as 
the pus ceases to produce the characteristic pustule, the ulcer 
may be considered an ordinary idiopathic one, and treated 
as ulcers in general. Calendula, in the absence of special 
indications, has acted promptly in my hands. 



272 



ELEMENTS OF SURGICAL PATHOLOGY 



It is of the utmost importance that care be taken to avoid 
the lodgment of the pus where it may excite a new develop- 
ment; for this purpose cleanliness is of the first value, and the 
destruction of all soiled articles of dressing, or clothing, by 
fire. The hands of the patient, attendants, and physician 
must be scrupulously looked after, to guard against infection of 
their own persons, as well as of others with whom they may 
come into contact. Under the most favorable circumstances 
the Course of the disease will be slow, and call for close indi- 
vidualization in the selection of remedies. The indications 
for remedies will be found in an earlier chapter, Ulceration. 

The bubo is to be opened freely, as soon as pus is detected, 
like any acute abscess, and the formation of pus hastened" by 
poultices and Hepar sulfih. When opened, the bubo must be 
treated precisely like the ulcer, viz., cauterization, and the 
indicated remedy. 

PRIMARY SYPHILIS- 
In the whole catalogue of diseases there are none that 
entail more serious consequences than syphilis. In most 
instances morbid action, even of the most formidable char- 
acter, is confined to the individual; in the case of syphilis, 
however, there is a promise that the consequences w r ill appear 
in the offspring, and for uncertain generations. Unlike most 
of the venereal contagions, the existence of syphilis is not 
dependant upon sexual commerce, so that the primary disease 
may be contracted, and numbers of other innocent persons 
infected, with transmission to their descendants, without im- 
putation on the chastity of the original donor. A case in 
point is given by Van Harlingen [Inter. Encyc. of Surg., n., 
451) as follows: "A young girl returning from a ball, kissed 
on parting the young man who had accompanied her home. 
She had been suffering from a cracked lower lip, and was 
consequently not alarmed when a ' fever blister ' appeared in 
the locality a few weeks later. As this did not heal she 
sought relief after a time at a dispensary, where burnt alum 
or borax was applied for several weeks longer, the sore grow- 



PRIMARY SYPHILIS 



73 



ing larger and harder all the time, and -kernels' appearing 

under the chin. When I saw her. at this time, the girl had a 
well-marked chancre on the lower lip. with hazel-nut sized 
induration, and accompanied by enlarged submaxillary glands. 
On enquiring as to the health of the family I learned that an 
infant sister, of whom my patient was very fond, had for 
some little time past showed • fever blisters' on the commis- 
sure of the lips, and on visiting the house I found the child 
suffering with a small chancre of the commissure, together 
with a general maculo-papular eruption. I at once quaran- 
tined the victims of the disease, but too late, as the mother 
and two more children subsequently showed generalized 
syphilitic eruptions, and the family remained under my care 
and observation for several years, showing various early and 
late lesions from time to time." 

Syphilis may be described, as a contagious, specific disease, 
originating in sexual commerce, for the most part, and con- 
taminating the whole organism. The initial lesion is always 
the characteristic sore, the chancre, no matter what the source 
of the contagion may be. whether from a primary, or later 
product of the disease, appearing at the point of contact. 
The so-called chancre, is not syphilis, it is only the initial 
svmptom: svphilis is manifested by later phenomena. The 
blood of a syphilitic, and most if not all of the excretions are 
capable of communicating the disease to an unprotected indi- 
vidual, but in every instance the first symptom is the char- 
acteristic chancre appearing at the point of contact. The 
literature of this subject is so vast, proportionate to its impor- 
tance, that it is almost impossible to arrange the mass of 
material in a condensed form and retain enough to make it of 
much practical value. The fact that every organ in the body 
becomes affected, in a certain order, each with pathological 
features peculiar to itself; that the offspring of syphilitics 
show forms of the disease unknown in their progenitors: that 
constitutional peculiarities, or dyscrasias modify the manifes- 
tations in a variety of ways; that climate, social habits, and 
occupation, as well as social condition all have a potent in- 



274 ELEMENTS OF SURGICAL PATHOLOGY 

fluence in determining the vigor of the morbid action, to say 
nothing of the influence injudicious treatment may have, com- 
bine to render the subject one that cannot be adequately 
treated in a single essay. The student must go to special and 
systematic works for full information, and then will find much 
of uncertainty and incompleteness in certain directions. From 
the fact that syphilis has probably existed from the first ap- 
pearance of man on the earth, and must consequently be 
widely diffused throughout the human race, it is thought by 
some excellent observers that it must enter into the etiology 
of most if not all of the chronic diseases. As surgical patholo- 
gists, however, our enquiry is confined to the earlier manifes- 
tations of the disease, with a very general consideration of 
some of the later forms. It will be noted at this time, in pass- 
ing (the matter requiring further consideration later), that the 
pathological character of syphilis is, to a certain point of de- 
velopment, constructive, new tissue being laid down, under- 
going a certain organization, and then breaking down. From 
the fact, also, that the chancroidal disease is one of purely 
local consequence, the syphilitic being general, and in each 
case the invasion announced by the appearance of certain 
local lesions, it becomes a matter of the first prognostic, as 
well as therapeutic importance, that the character of this 
lesion be at once recognized. I shall accordingly essay reason- 
able minuteness in the description of the chancre. 

The contagious principle of syphilis, is contained in the 
pus-cell, the corpuscular element in any infectious substance. 
Careful experiments made by Puch and others seem to estab- 
lish the fact that the serum is innocuous, the cell being the 
vehicle. The same peculiarity has been observed in the 
blood. It seems to be a question of quality altogether, the 
quantity of contagious material being a matter of indifference, 
the same results, both in kind and degree, following inocula- 
tion with either large or small amounts. Next to exposure to 
contagion, the first essential is that the virus shall be brought 
into contact with a surface capable of absorption. Not having 
any of the irritating properties of the chancroid pus, it may 



PRIMARY SYPHILIS 275 

remain in contact with an unbroken surface for a long time 
before it will be taken up. So necessary is capability of ab- 
sorption to contagion, that there are many cases of undoubted 
authenticity, in which a woman has had intercourse with a 
syphilitic, and some hours afterward with a non-syphilitic, 
communicating the virus from the first to the second, and 
escaping infection herself. While inoculation is oftener 
effected through sexual commerce, yet the infectiousness 
of the blood, at least some of the excretions, and the 
products of late forms of the disease, afford numerous illus- 
trations of communication through many different channels — 
children become infected by nursing from syphilitics; lovers 
from kissing; members of the same family or social circle 
from common use of articles of the toilet, or table furniture 
and utensils; exchange of clothing, contact with privy-seats 
or urinals, and numberless other channels of mediate contagion 
furnish mam' examples. In all of them, regardless of the 
source, mediate or immediate, or the stage of the disease, 
primary, secondary, or tertiary, the result is the same, viz., 
the syphilitic chancre at the point of contact. There is much 
uncertainty as to the length of time that must elapse before 
the virus, outside of the body, loses its virulency. A case is 
mentioned by Van Harlinger. (/. <:., p. 452), in which an old 
man of seventy years of age, who had not had sexual inter- 
course for man}- years, had a chancre on the glans penis, from 
friction on a pair of pantaloons that he had worn for some two 
months, formerly worn by a syphilitic. Hovrever communi- 
cated, mediately or immediately, after absorption a certain 
length of time elapses before any further developments occur. 

This period of incubation is always prolonged, ordinarily 
ranging from fourteen to thirty-five days, rarely less than two 
weeks, although sometimes a much longer period than the 
limit is observed. 

Syphilis seems to be a purely human disease, there being 
no well authenticated instances of anything like it in the lower 
animals. Experiments have been made, and are still making, 
but up to the present time the results have been negative. 

T 2 



276 ELEMENTS OF SURGICAL PATHOLOGY 

The initial lesion, the chancre, of syphilis, appears in a 
variety of forms, for the most part quite inconspicuous, par- 
ticularly in women; it may be, in fact, so small and unobtru- 
sive that its existence may never be suspected. It is absolutely 
essential that it should be produced; every case of syphilis 
must have had a chancre, and, per contra, every chancre is the 
beginning of syphilis. Sometimes it appears as a small abra- 
sion or bloody spot; at others a dry papule, which drops off, 
after a time, and shows the raw surface ; again it is a fissure or 
crack, or assumes the pathognomonic ulcer form from the first. 
In the majority of cases the initial spot passes into the char- 
acteristic ulcer-form, but occasionally it does not. Whether 
ulcer or not, there is one constant feature, viz , the induration, 
which will be returned to later. The ulcer is small, with regu- 
lar sharply-cut outline, hard base and edges, sides sloping 
inwards like the mouth of a funnel, the base is smooth and 
shining, the areola is dark, almost black, or coppery; the pain 
is insignificant, or entirely wanting, and the discharge very 
small. The ulcers are usually single, if multiple they are of the 
same age, appearing simultaneously, at different points of inocu- 
lation. The discharge is hetero-inoculable, that is innocuous 
to the individual, or others who have had syphilis. Upon 
microscopal examination the elements are found to be forma- 
tive, not tissue-detritus as occurs in chancroid. The develop- 
ment of the chancre is slow, but it often disappears very rap- 
idly, sometimes spontaneously in four or five days — forming a 
very faint scar which soon passes away, leaving no trace 
behind it. Occasionally acute inflammation may occur in the 
chancre, converting it into a rapidly destructive ulcer, particu- 
larly in the case of those of a broken-down or debilitated 
constitution. Such an unfortunate occurrence seems to be 
more common in China, parts of South America, and Africa 
than elsewhere, for reasons that are not yet understood. The 
destruction of tissue under these circumstances may be very 
great, more than in the worst cases of chancroid, but it is not 
stated that the later developments of the disease are notably 
modified thereby. The distinguishing features of this primary 



PRIMARY SYPHILIS 277 

Stage, therefore, are the appearance of a small, painless, dry 
ulcer, single, and hetero-inoculable, with a peculiar induration. 

The Induration of the syphilitic sore is a very different 
thing, from every point of view, than that which sometimes 
accompanies chancroid. In the first place it oftens precedes 
the chancre, and usually outlasts it. It is of the same extent 
as the ulcer, that is does not extend beyond the margins of the 
ulcer. The induration is met with in two or three different 
forms; sometimes it is a thin parchment-like layer; at others 
solid, more or less spherical, but in whatever form it occurs it 
is non-inflammatory, sharply defined, feeling like a foreign 
body under the mucous membrane, and if not precedent to the 
ulcer, at least is contemporaneous. The chancroidal indura- 
tion it will be remembered, commences after the chancroid is 
established, thus constituting a distinguishing feature of syphilis, 
viz., a laving down of new tissue primarily, with secondary 
destruction of the tissues displaced. Thus we find, that the 
initial lesion commences in the deposit of a fibrinous exudate, 
that undergoes a perfect organization; the nutrition of over- 
laying parts is destroyed, a granular disintegration occurs, 
without a suggestion of inflammatory action, constituting the 
chancre. Active inflammation may be set up, accidentally, and 
the induration destroyed; if this should occur early in. the case, 
it is possible that the disease may be aborted, as there is good 
reason for believing that the induration is the actual materies 
morbi; but it is far from being a general fact, as dispersion 
and lymphatic infection are simultaneous with the commence- 
ment of induration. 

Bubo in syphilis is notably different from that of chancroid, 
resembling rather the glandular enlargements of carcinoma. 
The buboes are generally multiple, like a string of beads, 
hard, painless, non-inflammatory, indolent and chronic. Occa- 
sionally they soften, undergo an imperfect suppuration, the 
contents are discharged as an albuminous, gluey, viscid sub- 
stance, and the further development of the disease ceases; it 
seems that the morbid material is thus eliminated from the 
bodv. The glandular enlargements, rarely commence until 



278 



ELEMENTS OF SURGICAL PATHOLOGY 



the time the chancre is about to disappear, occasionally not 
untii it has entirely healed, and in a few instances fail to 
develope at ail. The failure of any glandular enlargement, 
may possibly argue the disappearance of syphilis, but the fact 
is not yet satisfactorily established. At all events the buboes 
are characteristic and diagnostic, their existence, in typical 
form, proving the specificity of a suspicious lesion. Should 
they inflame and suppurate spontaneously, the probabilities 
would be that the initial sore was a " mixed " one, particularly 
if found to be both auto- and hetero-inoculable. From a 
purely syphilitic bubo, the pus (or its equivalent), will always 
be hetero-inoculable. The location of the bubo will settle the 
question, very often, as to the location of the primary sore, as 
in cases where the manner of contagion, mediate or immediate, 
is in dispute, as affecting the chastity of individuals. When 
in the groins, the lesion has surely been in the genital tract, 
but may possibly, even then, not be of venereal origin. 
When the sore has been elsewhere, the glands interior to it 
will be those affected. 

The chancre, and any ulcer resulting from the bubo, it will 
be noted, heals rapidly, as a rule, and leaves a very incon- 
spicuous scar, unless it should, from any cause, become 
inflamed. The induration, however, under the scar, will dis- 
appear very slowly. Such is the semeiology of the primary 
stage of syphilis, and before passing to the pathology, it will 
serve a useful purpose to compare it with that of chancroid. 



Syphilis. 

Incubat.on, 14 to 40 days. 
Tissues, all kinds affected. 
Race, confined to the Human. 

Lesion, erosion, papule, or ulcer 
Areola, dark, or coppery. 
Ulcer, sloping sides; sharp edges; flat 
floor, smooth and shining; small. 

Pain, little or none 

Discharge, scanty, and hetero-inoculable; 
formative elements. 



Chancroid. 

None. 

The same. 

Anologues, at least,) in lower 
animals. 

Pustule. 

Inflamed. 

Undermined sides, or steep; 
ragged edges ; rough, worm- 
eaten floor ; lustreless, large. 

Comparatively great. Compara- 
tively profuse. 

Auto-inoculable; tissue debris. 



PRIMARY SYPHILIS 



79 



Number i single or of same age. 
Process, o rga n i zation 

i"> : ■ ■iopinait, slow. 

Repair^ rapid. 

Cicatrix, small, inconspicuous. 

Budo, multiple, indolent. 

Hereditary^ as a consequence. 

Propiyiaxis, immunity from later expos 

ure as a rale. 
Secondary symptoms, almost sure. 
Local treatment, no influence. 



I n flam mat ory. 
Multiple, successive. 
Destructive. 

Rapid. 

Slow. 

Prominent, lasting. 

Single, inflammatory. 

Acquired, no hereditj 

No immunity. 

Rare or never. 
Curative. 



The characteristics of these two affections, it is evident, 
have little or nothing in commDn. It is true that grafting 
chancroid on chancre, or producing induration by caustics, or 
secondary symptoms by mercury or other drugs may confuse 
the semeiology to an extent to forbid a positive diagnosis; but 
in uncomplicated typical cases, it is evident that such a widely 
different semeiology must, in the nature of things, argue a 
difference in the morbid action. 

Pathology: — The essential nature of the syphilitic virus is 
not understood. There are many who think, with Lustgar- 
ten. that there is a specific bacillus, but the fact is far from 
being proven; even if there is, in the future, confirmation of 
this theory, it will throw little light on the actual etiology, as 
I am firmly convinced that the bacillus will be found to be a 
consequence, as is quite generally the case throughout the 
domain of pathology. Certain physical facts are known, and 
many conflicting theories are deduced therefrom. We know 
that the morbid principle is resident in the cell, which has all 
the characters of a leucocyte, save size; it is found of the 
1 \ inch in diameter, the normal leucocyte being 25 1 0Q , 
and Lydston [Syphilis, p. 25) assumes that it is a free nucleus. 
This, however, if the fact should be proven, would be a his- 
tological anomaly, as the syphilitic corpuscle has an exagger- 
ated, amasboid vitality, a property not attaching to free nuclei. 
In all other pathological processes, free nuclei argue degener- 
ative conditions rather than formative, and there seems no 
sufficient reason for a departure from the usual course in the 



2 8o ELEMENTS OF SURGICAL PATHOLOGY 

present instance. It seems to be a fact, nevertheless, the 
syphilitic corpuscle is a very small, degraded lymphoid body, 
and that it communicates specific characters to other normal 
cells with which it comes in contact. Finding entrance into 
the organism, it excites an accumulation of leucocytes at the 
point of lodgment, without inflammatory phenomena — which 
undergo a solid and firm organization. This induces destruc- 
tion of the overlying tissues, resulting in chancre, which is 
followed, or accompanied, by softening of some parts of the 
deeper portions of the new matter, detachment of elements, 
which are taken up by the absorbents, and as they enter the 
glands convert their products into syphilitic germs, excite a 
rapid production of new cells, of the same properties, inducing 
tumefaction of the gland (bubo)/ From this secondary base 
an increased number of infecting cells pass out, repeating the 
process in the next gland, attacking it with greater energy 
than the last, on account of multiplication of the elements, so 
that the gland becomes larger than the preceding one, and 
so on, from gland to gland, until the increasing size is lost to 
view by the chain extending into the deeper parts, and the 
infectious stream enters the general lymphatic current. The 
glands do not suppurate, because they are not inflamed; they 
are engaged in an exaggerated -production, it is true, but the 
organization of the product is more perfect than in inflamma- 
tion. Finally the blood is reached, and general syphilis is 
established. The blood now exhibits notable changes, which 
Van Harlingen (/. c, 476), describes as follows: "That the 
blood must undergo some change during the evolution of the 
syphilitic poison in the economy, has long been admitted, but 
the first scientific observations on the subject were made by 
Grosst, under the direction of Ricord. Grossi undertook a 
number of chemical analyses of the blood in persons suffering 
from venereal sores, and found that when these sores were 
not followed by subsequent syphilitic manifestations (chan- 
croid) the blood remained normal; while in cases where sub- 
sequent generalized symptoms resulted (chancre), the blood 
showed diminution of the globular mass with proportional in- 



PRIMARY SYPHILIS 2 8l 

crease of the albuminous constituents. Grossi's results were 
continued by Wilbouchewitch, of Moscow, who, desiring 
to study the influence of mercury on the composition of the 
blood, commenced by enquiring into its condition before the 
administration of the drug, and during the existence of chancre. 

••In ten cases studied by Wilbouchewitch, the average 
diminution of red corpuscles was 638,870 (the normal figure 
being taken as from 4,200.000 to 6,477,000), while the increase 
in the white corpuscles was 550, the proportion being one 
white corpuscle to 448 red corpuscles, instead of 1 white to 530 
red the average normal proportion. 

••Of course this impoverished condition of the blood would 
be likely to lead to various characteristic symptoms, and thus 
we find in some cases disorders of circulation, irregularity in 
the action of the heart, murmurs in the larger vessels, pallor, 
epistaxis. and occasionally cedema of the lower extremities. In 
addition, general malaise, loss of energy, and a constant sense 
of fatigue; nervous s}'mptoms, such as vertigo, insomnia, and 
headache, particularly of a temporo-frontal character; also, 
vague and confused pains of various sorts — sometimes in the 
muscles, giving rise to simulated torticollis, pleurodynia, or 
lumbago — at other times concentrated in the joints or in the 
shafts of the long bones; in a word, any or all of the symp- 
toms of an anaemic condition. 

"While these symptoms of anaemia are not well marked in 
every case of early syphilis, yet one or another is almost 
always present in cases of average severity.'" 

I have now given the established facts of the pathology of 
primary syphilis, which briefly summarized show, in common 
with all forms of morbid action, a local commencement, whence 
the general disease is propagated: to suppose any other order 
of development, would be contrary to common sense, as well 
as resting upon no foundation of established fact. The initial 
lesion once produced, later phenomena are certain in the nat- 
ural history of the disease, unless the infecting and infected cel- 
lular elements are thrown out completely through one of the 
glands. There must be a complete elimination, for a single 



282 ELEMENTS OP SURGICAL PATHOLOGY 

cell (yoaVoo °^ an i ncn ) remaining will set up specific action 
just as surely as a thousand. The organism becoming con- 
taminated, later forms of the disease are to be studied, but 
before doing so, something must be said of treatment. 

Treatment. — Considering the manner of contagion, and 
the nature of the morbid material, not originating in the body 
but conveyed to it from without; that there is no known con- 
dition of the body which will resist contagion other than 
previous inoculation; that contagion, is in a sense material, 
and the morbid action developes from it as a centre of organi- 
zation, it must be manifest to everyone, not blinded by prej- 
udice, that treatment, in the ordinary meaning of the word,. 
is and must be ineffectual. Remedies cannot change the state 
of a body so that it can resist such a powerful influence; they 
cannot destroy the infecting property of immigrant degraded 
cells. All that they can do, by any possibility, is to prepare 
the organism for the subsequent developments. It would 
seem, on cursory examination, that such an influence, purely 
local in its beginning, might be destroyed by direct treatment. 
Several causes combine to render such a thing if not impos- 
sible, at least improbable. First, there is no evidence of 
infection until the sore or the induration appears; then the 
poison has found entrance and lodgment, and dispersion with 
systemic infection has commenced. It is true scrupulous 
cleansing of surfaces that have been brought in contact with 
the syphilitic matter, might, probably would remove all danger. 
Unfortunately, however, either the suspicion of such contact 
does not exist, or else the alarm occasioned thereby may 
prompt to too vigorous an ablution, occasioning abrasion that 
furnishes favorable conditions for the admission of even one of 
these minute cells. In the second place, the first symptom 
being the sign of dispersion of the elements, caustics will 
only hasten and facilitate the process, and also expose the 
patient to danger of inflammation, which would probably add 
immensely to the gravity of the case. Excision is open to the 
objection of being indefinite, as no one can tell how far from 
the point of entrance the infection may have gone. In fact 



PRIMARY SYPHILIS 283: 

the universal verdict is, in all schools of practice, that local 
treatment is not only inefficacious, as to prevention of the 
disease, but even harmful to the patient. Unhappily the 
same verdict, to some extent, is universal as to so-called " con- 
stitutional treatment." With or without treatment, of any 
kind, the ulcer heals, and the buboes disappear in about the 
same length of time, and under all circumstances secondary 
symptoms appear. Indeed the speedy disappearance of the 
local lesions, seems to be a promise that the secondary mani- 
festations will come on earlier, and be more severe, than if 
more time was taken. A bubo may soften, and the contents 
be discharged, but it must be done spontaneouslv, by the vis 
medicatrix natur<B; if it is attempted artificially, the syphilitic 
leucocvtes are stimulated to unwonted activity, and dispersion 
goes on with increased rapidity. Hence I say, and I think all 
experienced practitioners will yield assent — primary syphilis is 
incurable, in the very nature of things. Some will ask: Do 
you let such cases go without treatment, therefore? I answer 
no! and for sufficient reason. It is true that treatment makes 
no impression on the initial lesion, and that secondary symp- 
toms are as certain to come as night is to follow day; no man 
ever saw a case of secondary syphilis that did not follow a 
primary chancre; and no man has seen a true chancre, 
unquestionablv syphilitic, that was not followed by secondary 
disease. These are facts. But it is within the experience of 
all men, that those who have judicious treatment in the pri- 
marv. develooe a milder secondarv disease, and one that is 
more amenable to treatment than those which have not had 
such treatment. There are cases, I am aware, reported on 
fairly good authority, in which no later symptoms have fol- 
lowed primary lesion; but it is safe to say that such lesion 
could not have been syphilitic, or else there was spontaneous 
softening, and suppuration of the bubo. Nothing can be 
prognosticated on the primary lesion; an insignificant erosion, 
with the least possible induration, and a barely noticable 
glandular swelling, may be succeeded by exceedingly virulent 
secondary and tertiary symptoms. The converse is also true, 



284 



ELEMENTS OF SURGICAL PATHOLOGY 



as well as that the same remark applies in each stage: that is, 
a mild secondary disease, may be followed by a malignant 
tertiary, and also the converse. Furthermore, while the' 
appearance of secondary disease within six months after the 
primary, is generally confirmatory evidence of the syphilitic 
character of an initial lesion, yet the failure of such develop- 
ment is not always to be esteemed proof to the contrary. 
There are cases in which such development has been delayed 
many months, and a few in which they never appeared, and 
yet children of the suspect had proof of the specific character 
of the parent's perhaps forgotten disease. Without multiply- 
ing instances and illustrations, sufficient has been said to make 
good the statement, that the primary disease may be con- 
sidered essentially incurable, and to suggest to those entertain- 
ing different views that the poverty of such testimony as they 
must necessarily rely upon, stands in the way of any positive 
assertions based upon a few cases, and these, probably, lost 
sight of soon after the supposed 4i cure" was effected. The 
only evidence that a cure has been secured must be furnished 
by the children and grand-children of the original syphilitic. 

The principles of treatment of primary syphiiitics, are largely 
expectant, in an uncomplicated case. Mercury v& undoubtedly 
the simillimum, the corrosives, at least in my practice, being the 
best form; I use it in the 30th attenuation, about four times a 
day. Such treatment will rarely satisfy the average patient, so 
that if he is not of a class to appreciate the problems involved, 
it will be necessary to use something that looks at least 
like direct treatment, vaseline, cosmoline, calendula jelly, or the 
like, may be used for purely moral purposes. The point of 
first importance, to remember in all cases, is that the utmost 
care must be taken to avoid any manipulations that would 
have the effect to excite inflammation. Should suppuration of 
the buboes threaten, every means should be taken to promote 
it, and on the first indications of softening, they should be 
freely opened. 

Another item of equal importance, but for different rea- 
sons — is to guard against infection of third parties. The same 



CONSTITUTIONAL SYPHILIS 285 

precautions are to be employed as in chancroid, with even 
greater care, inasmuch as the inoculation of another person 
would entail such disastrous consequences. 

CONSTITUTIONAL SYPHILIS. 

Within a month after the subsidence of the primary symp- 
toms, sometimes not until a year after — (and in some instances 
before the healing of the chancre) signs of general infection 
come on, affecting first the skin and mucous surfaces, and 
gradually extending to deeper structures, until the whole 
organism becomes infected to a degree that may destroy life. 
There is much diversity in the classification of these later 
manifestations: the most generally used is to call secondary all 
manifestations confined to the skin and mucous tissues; ter- 
tiary, those of the deeper soft parts, viscera, and bones; and 
congenital when the offspring are born with extensive lesions, 
not primary in character. When the infant has become inocu- 
lated from a mother with primary or secondary disease, it is 
often called infantile, as distinguished from the congenital. In 
this case the disease commences with the chancre, and runs 
through the typical course; in congenital, it already has late 
lesions, from the mother having progressed to constitutional 
symptoms. Should the mother be generally syphilized at the 
time of conception (when conception is very rare) premature 
delivery is the rule. In the Medical Record (March 24th, 
18S8, p. 330), is an editorial notice of a doctrine that seems 
to be well established. It says : " Syphilographers are now 
very generally agreed that a syphilitic woman may beget a 
syphilitic child without infecting her husband, and some believe 
that a man who is a sufferer from the disease in its later stages 
may beget a syphilitic child while the mother escapes infec- 
tion." 

" Although there is little doubt concerning the first of these 
points, there is, nevertheless, much dispute as to the time at 
which the child becomes infected. It was formerly held that 
a woman who did not acquire the disease before the seventh 
month of gestation would give birth to a healthy child. 



286 ELEMENTS OF SURGICAL PATHOLOGY 

Chabalier has reported a case in which a woman became 
infected sixty-three days before the birth of a syphilitic child. 
But an instance is now related by Dr. F. Sorrentino, in La 
Riforma Medica of December 23, 1887, in which the date of 
infection was but fifty-two days before delivery. 

" A woman, twenty-six years of age, of sound general 
health, had been married at the age of twenty to a coffee- 
house keeper, by whom she had had two healthy children 
born at term. In May, 1886, her hnsband left her, when she 
was two months pregnant, and went to Marseilles on business. 
He returned home on November 14th, and had intercourse 
with his wife at that time, infecting her with a syphilis which 
he had contracted during his absence. Fifteen days after the 
primary sore was noticed an extensive roseola appeared, 
which was treated energetically by subcutaneous injections of 
mercuric chloride. The child was born on January 5th, fifty- 
two days after the mother's infection. It seemed at first to 
be healthy, but soon manifested the symptoms of hereditary 
syphilis. There was no sore about the lips, mouth, or 
pharynx to suggest the possibility of infection from the mother 
post-partum. 

'* This case, if all sources of error can be excluded, would 
appear to demonstrate conclusively that a woman may give 
birth to a syphilitic child when her disease is contracted later 
than the seventh month of gestation." 

With this question, however, as well, indeed, as the whole 
of constitutional syphilis, the surgical pathologist has only a 
secondary interest; the dermatologist, ophthalmologist, peedol- 
ogist, and others, having to do with the different forms more 
directly. In cases of doubt and obscurity, such as very 
many are, the history of the case, as developing the existence 
of the primary disease, is all essential; without absolute proof 
of such an occurrence, there are many forms of constitutional 
disease that could not be detected, at least until valuable time 
had been lost. 

Hamilton {JPrin. and Pract. of Surgery, third ed., p. 
146) quotes the following table from Martin, which will be 



CONSTITUTIONAL SYPHILIS 



287 



found an exceedingly valuable guide in determining the syph- 
ilitic character of a doubtful lesion. The first column gives 
the date of usual appearance; the second the earliest noted, 
and the third the latest: 





SYMPTOMS. 


u S A L 
APP'CE. 


EARLIEST 


LATEST. 


I. 


Itoseola (Ecythema) 


45th day. 


25th day. 


12 mos. 


2 . 


Papular eruptions (Lichen) - 


65th day. 


28th day. 


12 mos. 


3- 


Mucous patches ... - 


70th day. 


30th day. 


iS mos. 


4- 


Sec. affec. of fauces 


70th day. 


50th day. 


iS mos. 


5- 


Vesicular erupt ons 


90th day. 


55th day. 


6 mos. 


6. 


Pustular eruptions 


Soth day. 


45th day. 


4 years. 


/ • 


Rupia ------ 


2 years. 


7th mo. 


4 years. 


S. 


Iritis 


6 mos. 


60th day. 


13 mos. 


9- 


Sarcocele 


12 mos. 


6 mo. 


34 mos - 


10. 


Periostitis 


6 mos. 


4 mo. 


2 years. 


1 1. 


Tubercular eruptions 


3 to 5yrs. 


3 years. 


20 years. 


12. 


Serpiginous - 


3 to 5J rs - 


3 years. 


20 years. 


*3- 


Gummy tumors -.--.- 


4 to 6 yrs. 


4 years. 


15 years. 


14- 


Onvchia ------ 


4 to 6 yrs. 


3 years. 


22 years. 


15. 


Exostosis 


4 to 6 yrs. 


2 years. 


20 years. 


16. 


Ostitis and bone lesions 


3 to 4 yrs. 2 years. 


41 years. 


»7- 


Perforation of palate 


3 to 4 yrs. 2 years. 


20 years 



The above gives the order of sequence of the various 
symptoms of constitutional syphilis, as usually observed, but 
there is some variation occasionally. The earlier manifesta- 
tions are occasionally absent, at least may be of such an insig- 
nificant character, objectively and subjectively, that they have 
never attracted attention. In part this is occasionally true of 
the secondary group, from 1 to 10, entirely; particularly do 
we find Rupia often absent, also Sarcocele. The fact that 
the secondary phenomena are of a mild 13'pe, gives no promise 
of equal benignity in the tertiary group (10 to 17). The 
natural history of the disease, uninfluenced by treatment, 
gives most extensive tissue changes in the tertiary stage, the 
unfortunate sufferer becoming an object of disgust to himself 
and others. 

I do not deem it within the scope of this work to enter 
more at length into these later forms of the disease, our 
province as surgical pathologists terminating with the close of 



288 ELEMENTS OF SURGICAL PATHOLOGY 

the primary stage. This is particularly true, as far as litera- 
ture is concerned, as the determination of specific characters 
in a given case, can be secured only by comparison with non- 
specific forms of the same or similar affections, and then, after 
all, to be confirmed by the earliest history. The student 
would naturally look to special treatises for such comparison 
and description, and to them reference is now made. 

Treatment. If the primary stage of syphilis is incurable, 
certainly the secondary, and probably the tertiary are quite 
different; it is doubtful, however, if as much can be said for 
the congenital form, as the very fountains of life are then 
poisoned. In most of the symptoms, in either stage of con- 
stitutional syphilis, Mercury will find a place in the therapeu- 
tics. Next in value, particularly in mercurialized cases — the 
Kali iod. must always claim attention. I have faithfully tried 
this remedy, in all attenuations, from the first to the highest 
of the Fincke "potencies," and uniformly failed in securing 
any curative results, or in fact results of any kind. In the 
crude form, in doses of five grains, many of the worst cases 
have been apparently cured promptly. One case of perfora- 
tion of the palate, with the greatest destruction of tissue I had 
ever seen, was cured in a surprisingly short space of time. I 
think, however, that the so-called tertiary symptoms are those 
in which this drug will be found to exert its best influence. 
But our therapeutics are not to be confined to these two rem- 
edies. Asa/., Aar., Nit ac, Arg. nit., Sarsaft., Thuja., and 
many others are to be used on purely Homoeopathic indica- 
tions, precisely as though the case were one of the non-speci- 
fic character. In the pure, uncomplicated cases, however, the 
indications will point to Mercury, and if this drug has already 
been used to excess, so that the patient is "mercurialized," 
then, the iodide of potash seems to stand as a specific remedy, 
on chemical, symptomatic, and experimental grounds. There 
can be no charge of "routinism," eclecticism, or "mongrel- 
ism" sustained here, as the disease is eminently specific, and, 
according to Jahr and the older homoeopaths, must have a 
specific remedy. 



XVII.— LITHIASIS 

Fluids in the body, that hold inorganic matter in solution or 
suspension, often undergo decomposition, throwing down the 
solids, which become calculi, lithic or calcareous. Such bodies 
are often found in the salivary glands, particularly, or in the 
lymphatics generally. The process may be pathological or 
accidental, but in either case is due to an excess of solids, a 
super-saturation, either relative or actual. If a solution is 
retained in a cavity, the watery portions may be absorbed, and 
the material held in solution thereby thrown down. This may 
be purely accidental; or there may be some fault in excretion, 
by which there is an excess of solids, or a diminution in water, 
in either case the solids being in excess, relative or actual. 

While lithiasis means the disposition to the formation of 
concretions, in any parts of the body, calcareous or lithic, by 
common consent the use of the term is restricted to the for- 
mation of calculi in the urinary tract. It is in this sense that 
the term will be used in the present article. Roughly stated 
the appearance of gravel in the urine represents an excess of 
the constituent forming the stone, either relative or positive,. 
and thus stands as the expression of some disturbance of 
nutrition. As a matter of fact the varied diet of nearly every 
one in civilized life forbids anything like constancy in the 
chemical character of the urine, the composition varying from 
day to day, and hour to hour; it is possible, therefore, to have 
an excess of urinary elements, at times, with no pathological 
state back of it. The persistence of a urinary abnormality is, 
on the other hand, always to be taken as an evidence of dis- 
ease. There are certain forms of urinary calculi that are 

V 289 



290 



ELEMENTS OF SURGICAL PATHOLOGY 



produced by changes in the urine after it has left the kidneys, 
changes produced in the bladder from purely chemical causes, 
and that have no significance of a pathological character. It 
is therefore of the first importance that the origin of a cal- 
culus, or its nucleus, should be accurately determined, for 
purposes of diagnosis, prognosis, and therapeutics: a state 
of the urine in the bladder, very often, would be as far 
removed from the action of remedies, as though it were in a 
vessel outside of the body. For instance, a stone originating 
in the bladder is nearly always due to the presence of a 
nucleus of foreign material, the urine being normal in com- 
position, and the urinary function physiologically carried on. 
There is nothing for medicine to do, in such a case, as no 
change in the urine is desirable, the existence of the stone, 
under these circumstance, being evidence of the normal 
character of the urine. The sole indication is to remove the 
foreign body. Indeed this is the first indication in all cases of 
vesical stone, but the significance attaching to origin does not 
stop here. If the stone is of renal origin, its removal from 
the bladder will not cure the patient, as recurrence must 
ensue; the urinary function must be ordered. If the calculus 
originates in the bladder, its removal may be considered a cure 
of the patient. Thus we find it necessary to study urinary 
stone, under various headings, such as: Renal, Urethral, Vesical, 
Prostatic, and U'reteral-lithisiSis. Before taking up these 
topics, a word must be said of the composition of the urine, 
its physiological importance, and the conditions under which 
its constituent proportions are altered. Taking the mean of 
a large number of examples, the normal composition of urine 
may be thus stated (Dalton, Phys., p. 327, 7th ed.) : 



Water ----- 950.00 

fUrea - 26.20 

! Creatinine - 0.87 
Organic -j • ,. _ 

, oodmm and potassium urates - 1.4^ 

[^Sodium and potassium hippurates 0.70 



Nitrogenous 

Organic 
Substances. 



LITHIAS1S 



291 



( Sodium biphosphate 

, _ , I Lime and magnesium phosphates 

Mineral Salts. -\ ,. • . ° . ' , . \, 

J Sodium and potassium chlorides 

I Sodium and potassium sulphates 



1 of 


O.83 


12-55 


3-30 


0.35 


[ OOO.OO 



Mucus and coloring" matter 



This gives, in round numbers, about fifty parts in a thous- 
and solids, but, it will be remembered, the solids are not 
present as such, being in solution. The appearance of free 
solids must always be taken as evidence of abnormality, when 
occurring in freshly voided urine; urine that is retained in the 
bladder may undergo decomposition, precisely as though al- 
lowed to stand in a vessel outside of the body; the precipita- 
tion of the solids, to constitute a pathological state, must occur 
in the kidney, or deeper parts of the urinary tract. When 
the acidity of the urine is normal, there will be no precipita- 
. tion of solids, because all the acids are taken up by the bases; 
when the acids are in excess, that portion which cannot be 
taken up by the bases is free as a precipitate; when the alka- 
line bases are in excess, that portion of them which does not 
take up the acids, remains free, and an alkaline precipitate 
occurs. It is thus apparent that there may be an actual ex- 
cess of the constituent appearing in the precipitate, or a rela- 
tive deficiency of the element with which it should combine. 
Anything which would temporarily increase or diminish the 
acidity of the urine, as articles of food or drink, unusual exer- 
tion or fatigue whereby waste is exaggerated and urea in- 
creased, would have the effect to produce a precipitation of 
solids, but would not necessarily have a pathological signifi- 
cance, unless frequently repeated, or it became habitual. 
Such are the main facts, of interest at this time, of the compo- 
sition of the urine, and its normal variations, and yet, as a 
matter of diagnosis, it should be remarked, that the micro- 
scope and urinalysis may show all the conditions of lithiasis, 
and yet there may be no calculous formation; and, on the 
other hand, there may be stone, and no symptoms either sub- 



2Q2 ELEMENTS OF SURGICAL PATHOLOGY 

jective or objective. As a matter of fact, however, when the 
conditions of lithiasis are observed, the disease is existent, it 
not being essential that the calculi should remain within the 
body; the retention of the stone may be regarded as an acci- 
dental occurrence, the formation being the diagnostic feature. 

From what has just been written it is evident that habits of 
life, diet, drink, and possibly climate must have much to do 
with the lithic diathesis, and yet, as to races particularly, the 
data are very inconclusive. In fact nothing can be predicated, 
as to liability to lithiasis, on race, climate, or geologic conditions. 
It appears that the Rhenish provinces in Europe, and the New 
England states in America, are singularly free from calculous- 
disease, attributable, as some conclude, to the free use of light 
wine in the one, and cider in the other. Age seems to be an 
important factor, more cases occurring in voung people, and 
the aged, than those of middle life. Sex has an important 
influence, largely for anatomical reasons, at least as far as re- 
tention of stone goes. Probably lithiasis occurs with equal 
frequency in both sexes, but owing to the capacity, shortness, 
and comparatively simple construction of the female urethra 
retention is far less common among women than men. 

The facts briefly stated above, must be taken as a simple 
introduction to our present subject, and yet few as they are, 
and apparently essential, there are many exceptions. To 
fully treat of the formation of urinary stone, would require 
such an extensive review of physiology and organic (or 
physiological) chemistry, that the limits of this work would 
be far too narrow. While the excess of any acid, alkaline 
base, or urinary salt must stand as the actual and proximate 
cause for the appearance of a calculus, it must be remembered 
that excess may be not only merely relative, but constructive, 
to coin a word. .Thus at the normal temperature of the body, 
urinary solids will not be precipitated unless a nucleus is fur- 
nished; with lowered temperature precipitation will occur 
even without a nucleus. Thus the accidental introduction of 
a foreign body into the urinary tract, with the urine absolutely 
normal in all particulars, will result in a throwing down and 



LITHIASIS 



293 



crystallization of urinary salts at any time. Impediments to 

the evacuation of urine, cither by obstructions in any part of 
the passages, or paralysis of the bladder, will cause a neces- 
sary accumulation, with consequent decomposition, and pre- 
cipitation of solids. The fact will be stated again, but needs 
mention here, that the kind of precipitate — acid or alkaline — 
will depend largely on the characters of the nucleus; in the 
use of the word "foreign," also, organic bodies, originating 
within the body, are as much foreign as though introduced 
from without. Thus it makes no difference, whether the 
nucleus is a drop of blood, pus, or mucus, or a piece of bone, 
musket shot, or the like. The curious fact to which attention 
is called, is that when the nucleus is soft, the resulting con- 
cretion is uric acid, or the calcic-oxalate; when the nucleus is 
hard, the concretions are phosphatic. It is noticeable, that in 
the large majority of calculi of uric acid, the nucleus is nearly 
always found to be a clot of blood, or drop of mucus. 

Before taking up the study of the varieties in lithiasis, 
something must be said of the physical characters of the stone, 
as to shape, size, number, consistency, and the like, in other 
words the macroscopic features. First as to the material. 
While any one of the urinary salts, acids, or alkaline bases 
may form the body of a stone, there are some that are more 
common, either singly or combined. These are uric (or 
lithic ) acid, alcic- oxalate, calcic-phosphate, and the triple (or 
ammoniaco-magnesic ) phosphate. 

Uric Acid is seen, under the microscope, in the form of 
crystals of various shapes, chiefly rhombic, or lozenge-shaped, 
with the angles rounded off. They are either colorless, or 
stained yellow by the coloring matter in the urine. 

Oxalate of Lime, due, as will be seen later, to acid decom- 
position of urine, appears as minute, clear, transparent crystals, 
either octahedral or "dumb-bell" in form, when simple; when 
compound they assume a somewhat complex shape, on first 
view, and also when viewed from different positions. Thus 
crystals are seen that present an angle to the observer, and 
others that are compound from the union of two. Combina- 



294 



ELEMENTS OF SURGICAL PATHOLOGY 



tions may, however, be to any numerical extent, so that the 
resulting shape may be very confusing. 

Calcic-Phosphates may sometimes be amorphous; when 
crystallized they are of irregular form, as to outline, being 
ragged, and of a white color, tinged with yellow, in some 
instances. There are certain "dumb-bell" forms, however, 
but they are very different from the calcic-oxalate. These 
deposits usually appear as a result of alkaline decomposition. 

Triple-Phosphates, or the ammoniaco-magnesic phos- 
phates — likewise appear as a result of alkaline fermentation, 
the alkaline excess being ammonia. The form of the crystal 
depends upon the rapidity of the process, being stellar when 
rapid, and prismatic when slow. 

While other substances are frequently found as elements of 
stone, the above constitute fully ninety per cent, of all urinary 
calculi. The stone may be composed of a single element, sur- 
rounding the nucleus, constituting the simfle form; or there 
may be an arrangement of layers, or incrustations, sometimes 
each layer of a different element, forming what is known as a 
compound stone. The physical characters of calculi may be 
described as follows: 

Numbers: — There may be a single stone in the bladder, or 
in any number from two to several hundred. When single 
the origin is usually vesical, but a final decision on this point 
must be determined by the nucleus, to be returned to later. 
When multiple, the origin is quite surely renal, and the con- 
dition is certainly pathological. Single stones are usually 
phosphatic, or phosphatic with a uric or calcic-oxalate en- 
velope. Multiple stones, are either uric acid or oxalate of 
lime. Occasionally, however, a stone becomes fractured, and 
two or more calculi may exist notwithstanding the origin is 
vesical. Number, therefore, cannot be held as conclusive 
evidence as to origin, unsupported by other facts. 

Form: — There is great variety in the form of urinary 
stones, depending upon many circumstances. When single, 
they are irregular, from the direction of growth given to them 
by their surroundings, or the form of the nucleus, particularly 



LITHIASIS 



295 



when one portion, the oldest, is encysted or held in any way, 
the accretion then being on the free part. When there is 
more than one stone, attrition of one on the other smooths 
down sharp angles and other irregularities, until they become 
more or less spherical — Single stones are quite frequently 
ovoid or spherical, when free in the bladder, from the constant 
change of position to which they are subjected. The density 
of the calculus has much to do with the shape. Solid heavy 
stones, such as the oxalates and lithic acid, from their manner of 
growth, are quite regularly ovoid, being laminated, or concen- 
tric. Soft phosphatic calculi are much more irregular in 
growth, and consequently of no constant form. 

Size: — The size of calculi is very variable; when sufficient- 
lv large to be worthy of the name of stone, they are from the 
size of a grain of wheat, to a mass as large as a billiard ball. 
Multiple calculi are smaller as a rule, and thus small stones 
are more likely to be of renal origin than large ones. This 
presumption is increased from the fact that small, multiple 
stones are generally of uric acid. 

Color: — Each variety of stone has its peculiar color. Some- 
times, in cases where the bladder is exceptionally irritable, the 
outside of the stone will be stained by blood, or coloring mat- 
ter from the urine, so that fracture will be necessary to deter- 
mine this point. The phosphatic stones are white, or grayish- 
white like plaster; the uric acid yellow, or pale brown; the 
oxalates are dark-brown, even approaching black. 

Consistency: — Stones of a firm close texture, hard, and not 
easily fractured, are either uric acid, or oxalate or lime, the 
latter being the hardest. The phosphatic stones are of loose 
texture, and friable; occasionally, particu 7 arly with the calcic 
phosphates, there is no organization of stone, the material be- 
ing disposed in masses like fresh mortar, or sand. 

Weight: — The heaviest stones are the oxalates, next the 
uric, the phosphates lightest. In some instances these calculi 
are so light that they float on the urine in the bladder. 

Odor: — In most cases the stones are odorless, but frequent- 
lv it is otherwise, the odor bein^ peculiar to each variety. 



296 ELEMENTS OF SURGICAL PATHOLOGY 

Thus the phosphatic concretions have a fetid, or ammoniacal 
odor, as they are calcic or triple; the uric acid has a urinous, 
and the oxalate a seminal odor. 

Nucleus: — When other distinctive characters are wanting, 
or negative, inspection of the nucleus will often give desired 
information. Thus if a clot of blood, drop of pus. or mass of 
vesical epithelium is found, the stone originated in the bladder: 
if a crystal of uric acid, oxalate of lime, or renal epithelium 
forms the nucleus, there has been a renal lithiasis. Of course 
a nucleus of foreign material, such as a gun-shot, piece of 
catheter, hair-pin. or the like, would definitely settle the ques- 
tion of renal or vesical origin. 

There are cases in which something may be told as to the 
kind of lithiasis in advance of an inspection of the calculus, by 
an examination of the urine. It is true that urinalysis, as a 
rule, is quite inconclusive, as said earlier, as stones may exist 
in the bladder, and the urine give no indications, and the re- 
verse. Then again a stone may be formed from renal lithia- 
sis. and the renal disease subside. Nevertheless there are 
cases in which the disease does persist, and the urine will give 
the testimonv. 

It must not be forgotten, that when the urine is found load- 
ed with the elements of stone, the lithic disease is present, 
whether distinct concretions exist or not. Also these elements 
may be found in the urine, coming from disintegration of a 
phosphatic stone, or a failure in cohesion. 

The examination of urine, therefore, is not of value as de- 
termining the existence of stone in the bladder, but as settling 
the question of a lithic diathesis. The inspection of the urine, 
without chemical processes, is often of value. Thus when the 
urine is putrid, soon after passing, and has an oily-looking 
pellicle, the presumption is an excess of calcic or amorphous 
phosphates. When either putrid or ammoniacal (oftener the 
latter), and the pellicle is iridescent, triple phosphates are the 
rule. A sediment of red or yellow sand, the common " brick- 
dust " deposit, is usually uric acid; when a glassy, tenacious, 
and gritty deposit exists, the presumption is in favor of oxalate 
of lime. 



LITHIASIS 297 

The student has at his command certain simple tests that may 
be useful. Thus if a suspicious specimen clears up under heat, 
the deposits are urates. They can be reproduced by cooling 
the specimen, or adding a drop of acid. A suspicious gravelly 
deposit, ma}' be roughly tested as follows: Potash or soda, 
will dissolve uric acid; nitric acid, will clear up the oxalate of 
lime deposit without effervescence. The phosphates are un- 
changed by heat, but are dissolved by acetic acid. Bryant 
(Surg'., p. 573). puts it in this summarized form; 

-Heat, dissolves only the urates of the urine. 

"Potash, dissolves all deposits except the phosphates and 
oxalate of lime. 

^-Hydrochloric Acid, dissolves all except uric acid." 

Occasionally a more determinate test is required. Some of 
the more useful are as follows : 

Uric Acid : — Expose the suspicious sediment to the fumes 
of ammonia, and if it be uric acid, a beautiful crimson color 
will appear, due to the formation of the purpurate of ammonia. 
This is known as the murexide test. 

Calcic Oxalate: — -In addition to the tests noted in another 
place, should there be any doubt as to the sediment, the failure 
of the murexide test would negatively determine the absence 
of uric acid, and thus presumptively determine the presence 
of calcic oxalate. Uric Acid, however, may be present as 
well as oxalate of lime, and therefore the onlv positive test is 
the microscope. 

In some one or more of the processes noted the determina- 
tion of the nature of urinary deposits may be made, and some 
information thus obtained of the source, a matter of the first 
therapeutic and prognostic importance. There are some who 
look with suspicion on all such statements, as tending to what 
thev call "mongrelism" in therapeutics. A moment's consid- 
ation, it would seem, should effectually dissipate such a fear. 
Calculi originating in the bladder, to repeat a former state- 
ment, may be due to a nucleus of foreign material, or the 
products of some vesical abnormality, such as inflammation, 
irritability, or tumors, or the decomposition of urine retained 



298 ELEMENTS OF SURGICAL PATHOLOGY 

by reason of stricture, acute or chronic, or the changes in the 
organ, due to old age. Such calculi are generally phosphatic r 
or if uric acid will furnish evidence as to source from inspec- 
tion of the nucleus. When such evidences exist the indication 
as to treatment is plain; if the nucleus is extraneous, the re- 
moval of the stone is the beginning and end of therapeutics- 
Should the nucleus be a product of vesical abnormality, simple 
removal of the stone cannot be considered curative, while it is 
a very essential step in the process. So also with nuclei 
originating in the kidney. As to -prognosis, the application is 
easy; inspection of the stone, and a study of the constant 
urinary characteristics will determine the question of liability 
to recurrence. 

RENAL CALCULI. 

Renal Calculi are urinary stones formed in the kidney,, 
depending upon some morbid agency operative in the kidneys,, 
or a general disorder of nutrition. Remembering that there 
may be a profound lithiasis without the formation of a stone, 
the urine being loaded with the elements, but further organiza- 
tion not occurring; and that such consequences maybe purely 
temporary, from some indiscretion in diet and drink, it will 
only be necessary to recall an earlier observation, that 
increased acidity, or alkalinity is the proximate cause for the 
appearance of the calculi. There are cases in which the urine 
is always loaded with a sandy deposit, constituting what is 
known as "gravel," and it may be stated as a rule that the 
usual fate of a renal calculus is to pass out into the bladder,, 
and so to the outer world, without giving rise to any subject- 
ive symptoms. In such cases, however, the masses are too 
small to be worthy of the name " stone," being, for the most 
part, simple or compound crystals, of microscopic size. Occa- 
sionally, however, larger masses will form, and either make 
their way to the bladder, giving intense suffering (the col- 
lective symptoms being known as nephralgia, nephritic colic,. 
etc.), or are retained in the the kidney, causing hydro- or pyo- 
nephrosis, with more or less complete destruction of the 



RENAL CALCULI 299 

organ, or even causing death. Before giving the semeiology 
of these different states, it will be necessary to glance at the 
conditions favoring the various forms of lithiasis. 

Uric Acid lithiasis, the most common, is due to sub-oxida- 
tion, whether from defect in the process itself, or on account 
of the increased waste. Accordingly we find most cases 
among the overworked, mentally and physically — or those 
whose occupation is very sedentary and monotonous, particu- 
larly if they consume much nitrogenous food, or eat hastily and 
to excess, returning to their work again without sufficient 
repose. In short the typical American business man is at one 
end of the lithic diathesis, and the farmer next to him in 
order of predisposition. There is another class of cases, how- 
ever, that more surely develope lithiasis, viz., those with 
affections of the heart or lungs that induce venous stasis. 

Calcic-Oxalate lithiasis is a result of the excessive use of 
starchy food, living in badly-ventilated houses or rooms, bodily 
inactivity, and the use of alcohol. Such persons become 
hypochondriacal, lose interest in their occupations, are drowsy 
during the day, and yet sleep poorly at night. If the urine is 
examined, the characteristic crystals will be found, and the 
affection is recognized as oxaluria, one which quite surely 
leads to nephritis in some destructive form. There are two 
circumstances that must be borne in mind, however, normal 
urine is frequently found with crystals of oxalate of lime after 
it has stood for twenty-four hours or longer, having undergone 
an acid fermentation; hence oxaluria can only be established 
by the examination of specimens less than a day old. Still 
there is room for doubt, the age of the patient, or states of 
the bladder being important factors. Any condition of the 
urinary passages that would produce retention of even a smal 
amount of urine (such as stricture of the urethra, sinking of 
the floor of the bladder, sacculation of the ureters, or the like) 
would furnish favorable conditions for acid fermentation, and 
throwing down of oxalate of lime crystals. 

Phosphatic lithiasis is largely due to osseous diseases, such 
as rickets, or to over-work in the mental sphere. The condi- 



300 ELEMENTS OF SURGICAL PATHOLOGY 

lions of the urine are very significant in this direction: in one 
case a diversion of bone-salts or elements is shown: in another 
an excess of earthy phosphates, and in still another exagger- 
ated waste. The amorphous phosphates (calcic) are simply 
"thrown out of solution." the triple are the result of an excess 
of ammonia, and the crystallized calcic phosphates an excess 
of calcium. So. also when the crystallization of the triple 
phosphate is stellate, showing a rapid formation, it would 
indicate changes in the urine in the bladder. Such crystals, 
and the amorphous or earth v phosphates, are simply the 
result of alkaline decomposition in the bladder, and are of 
minor pathological importance to the prismatic triple, or crystal- 
lized calcic phosphates, which show a derangement farther 
back, and consequently more profound. 

Nephralgia. — The natural history of renal for nephritic) 
colic, and the semeiology, is something as follows: A crystal 
of some kind lodges in one of the tubules, perhaps in the 
renal pelvis, or even in the glomerulus, and soon serves as a 
nucleus for other crystals until a calculus of appreciable size 
is formed. It may remain for an indefinite time without pro- 
ducing any symptoms, but on some jar of the bodv. or an 
unusual accumulation of urine behind it. dislodgment occurs, 
and symptoms suddenly appear. I think the majority of cases 
occur in the morning, just before or after rising. Xext in 
frequency such exciting causes as jumping from a carriage or 
street car. However dislodgment is effected, it is announced 
bv a sudden and severe pain, not localized, "somewhere in 
the abdomen"" — gradually increasing in intensity, extending 
from the pelvis, or the lumbar region, into the glans penis. 
and down the thigh. The pain increases to such a degree 
that the most courageous and phlegmatic men are completly 
unnerved, rolling on the floor, and contorting the body: the 
body is often bathed in a profuse perspiration, and more or 
less nausea is experienced from the first. There is urging to 
urinate, but the amount of urine is small, and the effort seems 
to increase the sufferings. Finally, varying from two to ten 
or even fifteen hours after the commencement, there is retch- 



RENAL CALC1 301 

ing and vomiting with great nausea, and a sudden subsidence 
of the pain, with copious urination. The urine ma}- be more 
or less bloody, and occasionally the stone, not larger than the 
head of a pin, will be expelled. The pain ceases, but there is 
much soreness and lameness for a day or so, and the exhaus- 
tion is considerable. The cause of this veritable agony is the 
passage of the rough calculus along the ureter, the mechan- 
ism of which is as follows : The first effect of the dislodgment 
of the calculus, and its entrance into the ureter, is a spasmodic 
contraction of the muscular fibres, and severe pain. Later the 
sensitive lining membrane becomes somewhat more tolerant, 
and the peristaltic action of the three layers of muscle gradu- 
ally forces the intruder onwards to the bladder. The accu- 
mulation of urine interior to the stone, has the effect to some- 
what dilate the passage, facilitating its movement, the irrita- 
tion extending to the kidney determining an increased excretion. 
When the stone enters the last portion of the canal, where it 
passes for some distance between the coats of the bladder, 
the pain is increased, the continuity of tissue causing more 
distinct localization, and at the same time increasing the 
nausea. The nausea and vomiting now has the effect to 
induce muscular relaxation, the retching at the same time aid- 
ing the pressure of the urine behind the calculus, which drops 
into the bladder, followed by a rush of urine, and cessation of 
pain. This is the natural history of nephralgia; all cases do 
not terminate so happily. 

Treatment: — The treatment presents a number of indica- 
tions. First, the passage of the stone must be facilitated. 
Second, the lithiasis must be cured to prevent a recurrence. 
It seems to many that the condition being, as they say, a 
"purely mechanical" one, narcotics or anaesthesia must be 
used. A moment's consideration, I think, will show this to be 
a great mistake, from all points of view, "mechanical" and 
scientific. The first and most important consideration in the 
case is, that the passage of the calculus shall be facilitated and 
assured; its lodgment in the ureter will be disastrous; a pro- 
longed passage, from the amount of injury inflicted on the 



302 ELEMENTS OP SCRGICAL PATHOLOGY 

tissues, may produce stricture of the ureter, a condition only 
secondary, in gravity, to lodgment. Certain passage can only 
be secured by the accumulation of the urine behind the calcu- 
lus, and the peristaltic action of the ureter itself. Opiates 
suppress urinary excretion, and thus one of the most important 
factors is taken out; they also limit or destroy muscular irrit- 
ability, and the remaining one is negatived. Neither process 
may be completely arrested, but is certainlv dimished in force, 
and the passage of the stone is prolonged. If, therefore, 
moderate narcotism is induced the ureter is exposed to injury 
that may imperil the life or comfort of the patient; and if the 
narcotism is complete or profound, there is danger of arrest of 
the stone, and destruction of the kidney, or the life. The ob- 
jections to narcotics do not end here: They diminish the 
water in the urine, relatively increasing the solids, and subse- 
quent nephralgia is almost assured. Anaesthetics are only less 
hurtful, as the persistalsis is diminished while the urinary ex- 
cretion may not be interrupted. Hence from any point of 
view, mechanical and otherwise, as to the present and future 
of the patient, the use of opiates or narcotics is manifestly un- 
wise and dangerous. Fortunately we are not left weaponless 
in these emergencies. 

C/iina, in any attenuation, has never failed me in alleviating 
the sufferings, and shortening the duration of an attack. Its 
action can be explained on "rational" grounds, for those who 
delight in such things. It increases the urinary excretion, 
thus dilating the ureter, and consequently diminishing the 
pain and shortening the transit. It should be given frequent- 
ly, once in fifteen minutes, and the patient encouraged to en- 
dure the suffering from a consideration of the dangers attend- 
ing other procedures. We often find that persons who are 
treated on the so-called "rational" plan, are subject to frequent 
attacks, a history that does not attach to those treated as I 
have indicated. At the same time much benefit will be found 
in the use of hot applications, and promoting vomiting. 

The calculus having passed into the bladder, it must be 
watched for in the passages of urine; and examined with a 



RENAL CALCULI 303 

view to determine its character, as the curative treatment of 
the lithiasis is entirely dependent upon the chemical form. 
Should the stone be lost, other means as already described, 
must be employed. 

Uric Acid being the form, there are a number of remedies 
from which to make a selection. In the absence of any spe- 
cial indications Arsenicum occupies the first rank. Lycof odium, 
or ChamomiUa may be needed where there are general indi- 
cations, and in a few cases there have been symptoms calling 
for Sarsaparilla. The urinary symptoms are practically alike 
in all cases; the selection of the remedy must be made from a 
comparison of the general symptoms. It is possible to cure a 
lithic acid lithiasis with remedies alone, but the process will be 
greatly facilitated if attention is paid to the diet and habits of 
life, suggested by the conditions referred to in an earlier para- 
graph. Thus the food should be less nitrogenous, eaten with 
greater deliberation, and care taken to procure adequate recre- 
ation and amusement. "Chemical" treatment is useless, 
that is giving alkalies, so much in vogue in certain quarters. 
If the case is not aggravated thereby, which is often observed, 
there is a possibility of simply transforming the lithiasis into 
one of a different character. 

Oxalate of lime lithiasis, originating in the kidney, calls for 
a single remedy, I think, the JVitro muriatic acid. I have 
never used this remedy in dilution, probably from habit, but 
find doses of from one to five drops, three times a day, 
promptly curative as far as the appearance of crystals are con- 
cerned. For the oxaluria, which is at the bottom of the 
trouble, it will rarely be cured in this manner, and of course 
this is the essential feature in the case. Still the mere disap- 
pearance of crystals is not unimportant, as the lodgment of 
one of them may be a very serious matter. The remedies 
that seem to exert the most influence are A T ux vomica, and 
Bryonia, although the semeiology is so protean, that there are 
few remedies that may not be indicated in different cases. It 
is impossible to give the indications for remedies without 
transcribing whole pages from the Materia Medica. The 



304 



ELEMENTS OF SURGICAL PATHOLOGY 



chief point to be borne in mind is to first correct the tendency 
to formation of crystals, then give the remedy indicated by 
the general symptoms, and correct faulty habits of life. 

Phosjyhatic lithiasis is often temporarily arrested by the use 
of acids in the food, but this must not be carried too far, or a 
uric acid lithiasis will take the place of the alkaline. The use 
of remedies must as far as possible be guided by indications 
outside of the urinary tract, such as an osseous disease, active 
or latent. 

Calcarea, Phosphorus, Si/icea, or Mercurius, are oftener 
indicatedc At the same time, as in all these cases, the habits 
of life must be looked into, and errors corrected. 

Retained Renal Stone: — Occasionally a renal calculus 
fails to pass out of the kidney, or it may lodge in the renal 
end of the ureter, whichever may be the case, the results are 
the same, in the end, only differing in rapidity of development. 
In the first case there will be a retention of urine behind the 
stone, which not only continues to accumulate, and thus 
damaging the structures — but undergoes decomposition, and 
adds to the size of the calculus by accretion. Other mal- 
phigian bodies or tubules are compressed, furnishing an en- 
larged area of retention, and the stone acting as a foreign irri- 
tant sets up inflammatory action, rapidly destructive of the 
kidney. Finally, one tubule after another being obliterated^ 
the parenchyma of the organ undergoes necrosis, from com- 
pression, breaks down, and a cystic degeneration of the organ 
is secured. Portions of the excreting tissues remain normal, 
or practically so, the effect being to continually add to the 
amount of fluid poured out, the cortex of the gland becoming 
thinned by expansion, and its function utterly destroyed. 
This is hydro-nefhrosis. In other cases, the calculus may set 
up a rapid and intense inflammation, passing into suppuration, 
until the cortex forms the pyogenic or limiting membrane of 
an acute abscess. This is -pyo-nephrosis. Should the calculus 
lodge in the uretal opening, the consequences are the same, 
with the difference that they are more rapidly developed, as 
there is no escape for any of the urine, all of which is retained,. 



RENAL CALCUL] 



3o5 



"choking" the kidney, as it is called, and inducing very rapid 
destruction. The consequences are various, in either case. 
The other kidney soon takes on compensatory activity, so 
that often there is no interruption in the excretion of urine, 
and consequently no symptoms of ursemic poisoning. Adhe- 
sions soon form between the walls of the abdomen, colon, or 
near viscera, and ultimately a fistula forms, with a discharge 
of pus and urine. The fistula, as a rule, is rarely of sufficient 
capacity to give exit to the calculus, which remains as a con- 
stant source of irritation, giving rise to a chronic abscess, with 
all the evil consequences of such a state of facts. Occasionally 
a fistula does not form, but pyaemia, septicaemia, or uraemia 
intervenes. 

The Symptoms of hydro-nephrosis, are obscure to a degree, 
particularly in the initial stage. There is rarely any symptom 
of lithiasis sufficiently pronounced to call the attention of the 
patient, and rarely any history of nephralgia to give warning. 
There is always some disturbance of the urinary function, as 
a matter of course, but it may be so slight that no attention is 
paid to it. This is particularly the case when the ureter is 
closed, when, beyond a diminution in the volume of urine for 
a day or two. and some indefinite uneasiness in the back, there 
is no remarkable departure from the standard of health. 
When the calculus is lodged in the kidney, there will be, in 
all probability, pus in the urine, but it may well escape notice. 
Later, in such cases, the amount of pus will be so great, with 
other evidences of renal disintegration, that the sufferer is 
liable to call for medical aid. When the ureter itseif is 
occluded, the amount of pus in the urine will be at all times 
small. When suppuration is set up there will be the custom- 
ary rigor, and. if attention is attracted to the urine, a suspicion 
of the actual trouble may be entertained, and the renal region 
examined. The loin will be found fuller than the opposite 
side: if adhesions have formed, palpation may determine the 
presence of fluid, and the aspirator show its character. If the 
adhesions are intestinal there may be no external signs. When 
the destruction is far advanced, the protuberance in the renal 

w 



o 6 ELEMENTS OF SURGICAL PATHOLOGY 

region marked and very prominent, the case is clearer, and 
spontaneous evacuation soon occurs. Even then strange 
errors have been made in diagnosis: caries of the spine has 
often been diagnosed, from the gritty character of the dis- 
charge, and the grating of the probe on the calculus. The 
discharge being into the colon, abdomen, or pelvis, a diagnosis 
may rarely be secured, at least ante mortem. There are cases 
in which an occluding calculus has become disintegrated, and 
suddenly giving way, permitting a free passage to the bladder 
of the contents of the renal cyst. I think the majority of such 
cases terminate, however, in the formation of a renal fistula in 
the loin, which may remain open and discharging indefinitely. 
Assuming a case of this kind, the probe, used intelligently, 
will detect the calculus, which is usually removed without 
difficulty, by nephrotomy. Should the aspirator reveal the 
nature of the case, nephrolithotomy is at once indicated. 
Further procedures demand a high degree of surgical knowl- 
edge. The question ofSfirst magnitude is. how far disorgani- 
zation of the kidney has gone, and whether nephrectomy is 
called for, or the remains of the kidney should be undisturbed. 
These questions are outside of my present limit, and must be 
answered elsewhere. 

URETAL CALCULI. 

Uretal calculus refers to one that has either lodged or form- 
ed in the ureter, in compliance with a custom of questionable 
propriety; properly speaking, the term should be restricted to 
the formation of the stone in the ureter, inasmuch as this must 
always be the chief point of interest. Nevertheless, long 
custom sanctions this misuse of the term, and it will be made 
to serve the present purpose. 

The lodgment of a renal calculus in the ureter is an accident 
of the most serious character. From the obstruction being 
complete, the destruction of the kidney by hydro- or pyo- 
nephrosis is almost certain, and much more rapidly accom- 
plished, than when lodgment occurs in the kidney itself. Un- 



[JRETAL CALCULI 307 

fortunately the semeiology of this accident is exceedingly 
indefinite, so much so that positive data are rarely furnished 
until the mischief is quite irreparable. The usual fate of the 
renal stone being to pass into the bladder, and this fulfillment 
being announced by a sudden and complete subsidence of all 
pain, when the nephralgia is marked, and the termination of 
the attack prolonged with an incomplete cessation, a suspicion 
may be entertained that the calculus has lodged in the ureter. 
In such an event the attendant would carefully watch the de- 
velopment of symptoms of choked kidney, such as rigors, 
perhaps uraemia, fullness in the loins, etc., and promptly make 
a nephrotomy. In many cases the urine will contain evidences 
of uretal mischief, pus or blood being present in larger or 
smaller quantities, but in the absence of more definite signs 
these go for little. 

The consequences of uretal lodgment, as to the ureter itself, 
and to the calculus, are important. When lodgment occurs at 
the upper part of the tube, anywhere, in fact, above its entrance 
into the bladder, ulceration soon takes place, and the calculus 
falls into the cavity of the pelvis, where it may set up a diffuse 
inflammation, leading to suppuration, f and ultimately will find 
its way out through the rectum, bladder, or some cutaneous 
fistula. When lodgment occurs lower down, between the 
coats of the bladder, it will oftener fall into this viscus, and the 
urinary function be restored again. Such an event is the 
common termination, as the anatomical structure favors lodg- 
ment of the stone at this point. 

As to the ureter, its future integrity and usefulness is very 
largely related to the location of the lodgment, and the fate of 
the calculus. Sometimes the tube above the calculus becomes 
tightly strictured, first from spasmodic muscular contraction, 
and secondarily by plastic exudation so that it is completely 
occluded. Below, a suppurative or ulcerative process is set 
up, the absence of urinary contact having the effect to favor 
disintegration of the stone, which is finally discharged into the 
bladder, and the inflammatory process ceases. In some cases 
the plastic material is later removed, and the patency of the 

W 2 



3o8 ELEMENTS OF SURGICAL PATHOLOGY 

tube restored, but such an occurrence must be very rare, and 
the kidney seriously injured before it can take place. 

The stone having found its way out of the ureter, into the 
rectum, colon, bladder, or vagina, the urinary function may 
go on undisturbed, although the channel may be an abnormal 
one. If the stone falls into the pelvis, or peritoneal cavity, 
the urine follows it, and thus greatly adds to the dangers of 
the case. In very many cases, however, the escape ^of the 
stone is followed by only a small portion of the imprisoned 
urine, adhesions and closure of the ureter above the point of 
exit being the rule. Under all circumstances, therefore, the 
lodgment of the calculus may be considered an accident of the 
most serious import, one which can scarcely be recovered 
from, except under the most fortuitous circumstances, the 
danger being greatly enhanced from the obscurity of the 
diagnosis. 

The causes for lodgment are many. The most common, 
probably, is the size of the calculus being greater than the 
capacity of the tube. In such cases the escape of the calculus . 
by ulceration is slow, and is only completed when the parts 
interior to it are destroyed. In other cases the shape of the 
calculus, irregular, with sharp points and angles, is the cause 
for unusual spasmodic excitement of the muscular fibres, and 
a firm retention of the stone. In such cases the irregularity 
of the calculus may permit an escape of some portion of the 
urine, and the sharp points or angles determine a more rapid 
perforation of the walls of the ureter. Such cases are better 
or worse than the former, depending upon the point of per- 
foration, whether into the pelvis or peritoneum, or some organ 
which gives ready exit to the urine. Undoubtedly cases of 
nephralgia that have been treated by opiates and the like, are 
exposed to danger of retention of stone far beyond other cases, 
not so treated, or that are even left entirely to nature. 

Uretal calculi, properly so-called, that is those that are 

formed in the ureter, have a somewhat different history and 

significance. The first essential, without which it is doubtful 

if a stone can form, is that there must be some kind of an ob- 



'AL CALCULI 



309 



Struction (such as stricture, with more or less sacculation), 
neoplasms. 01- Inflammation giving at once some exudate and 
a narrowing of the lumen of the tube. Being a lesion, there 
will always be at least a drop or two of residual urine, which 
must undergo some kind of decomposition, and elements of 
stone be thrown down. The slow accumulation of these 
elements has the effect to permit some attempt at compensa- 
tion in the tube, and thus postpone closure of the canal to a 
late day. if it occurs at all. The passage of the stream of 
urine over the calculus has the effect to wash away portions 
not firmly attached, and also to loosen the whole mass when a 
certain degree of development has been reached. On the 
other hand, fortunately in exceptional instances, the calculus 
may be so firmly imbedded, that it cannot be dislodged by 
such means, and while some fragments may be carried away 
in the stream of urine, there is much greater probability that 
accretions may be left behind. Unquestionably there are 
many cases of uretal calculi that have never been suspected, 
as they pass into the bladder upon attaining a certain size, 
and never give rise to any noteworthy symptoms. I saw a 
case, on the dissecting table, in which a papillomatous growth 
in a ureter had become encrusted with urinary deposits, the 
ureter being enormously dilated, and the kidney not ap- 
preciably affected. The circumstances under which a uretal 
calculi may form are of such a character, and the symptoms 
produced thereby so insignificant and unobtrusive, that a 
diagnosis is almost an impossibility. 

The Treatment, as might be imagined, can be nothing 
better than pure expectancy. As a matter of fact few cases 
will be presented for treatment until the renal disorganization 
is far advanced. Should lodgment of a stone in the ureter 
be suspected, it might be possible, in exceptional instances, to 
detect it through the rectum or vagina, in which case an 
incision would be proper. Ordinarily, when hydro- or pyo- 
nephrosis is established, the most that can be done is to make 
a nephrotomy, and either establish a urinary fistula, or if the 
disorganization has gone too far, a nephrectomy. 



310 ELEMENTS OF SURGICAL PATHOLOGY 

VESICAL CALCULI. 

Stone in the bladder is the form in which urinary calculi 
are generally presented to the surgeon. Preceding paragraphs 
have already referred to the usual source of stone., viz.. from 
the kidneys or ureter: the other sources are the prostate, or 
causes operating entirely within the bladder. x\mong the 
causes purely vesical, chronic or acute cystitis, tumors of the 
bladder of various forms, the accidental introduction of foreign 
material, or the retention and consequent decomposition of a 
portion of the urine, are among the more common, and some- 
thing in the order, as to frequency, as they are stated. A 
renal stone that has safely passed through the ureters, usually 
passes out of the body without difficulty. In some cases, 
however, it may lodge in a fold of the mucous membrane, 
and receive fresh accretions until too large to pass through 
the urethra. The stone once formed, is either free in the 
bladder, or "encysted," as it is called, that is surrounded by 
folds of mucous membrane, which retain it in one position, 
the swollen mucous membrane rising up like a wall around it. 
At times, and indeed usually, there is an accretion continually 
going on, until a large stone may be formed, projecting into 
the bladder, and firmly fixed. It is possible for such a stone 
to attain enormous proportions, and yet no symptoms pro- 
duced; after a time it may become dislodged, or broken, and 
sudden and urgent symptoms at once appear. 

In view of what has been said elsewhere of the formation 
of stone in general, it will not be necessary to enter at any 
greater length into the chemistry of vesical stone. The chief 
interest centers in the semeiology, and diagnosis. 

The first indication of stone in the bladder is usually an irri- 
tation and itching of the meatus urinarius, or the margins of 
the prepuce, inducing rubbing or pulling on the foreskin. 
Hence when young boys are found with a red and irritated, 
particularly an elongated prepuce, further examination for 
stone had better be made, or at least the case watched for 
other indications. This gradually increases, day by day. until 



3ICAL CALCULI 311 

it amounts to a pain. Associated with this are symptoms of 
vesical irritation, there being frequent demands to urinate. 
At first nothing unusual beyond the frequent micturition will 
be observed, but later pain will occur, at the close of the act, 
in the perineum, extending along- the urethra to the meatus. 
There will also be a sudden arrest in the flow, in the majority 
of cases, from the falling of the stone into the neck of the 
bladder, leaving the act uncompleted. These symptoms will 
increase in severity, until the constant urging to urinate, day 
and night, the increasing painfulness of the act, and the dis- 
turbed sleep and generally disordered functions consequent 
thereupon make life a burden, the face becoming haggard, 
and the expression one of suffering. As the stone increases 
in size, its motion over the surface of the bladder sets up a 
more or less violent cystitis, much aggravated by the contu- 
sion caused by forcible propulsion against the neck of the 
bladder at each act of micturition; the urine becomes loaded 
with mucus or pus, sometimes blocdy, and the bladder con- 
tracted and thickened. Later in the case, when the bladder 
is emptied, or nearly so, it shuts down, almost spasmodically 
on the stone, causing the most intense pain, which continues 
until some amount of urine is deposited, when shortly the 
urging to urinate will commence, followed again by the hor- 
rible pain. In the late stages the suffering is almost constant, 
the contraction and thickening of the bladder diminishing its 
capacity very greatly. 

There are cases, however, of large vesical stone, in which 
none of these symptoms occur, or in a modified form. This 
immunity is due to encystment of the stone. There are other 
cases in which the svmptoms, in an aggravated form, come 
on suddenly, " from a sudden release of a stone previously 
encysted. The most embarassing modification in semeiology, 
because, without previous information, an error in diagnosis 
might be suspected — is the sudden disappearance of symptoms 
from a stone becoming encysted, or practically so, by falling 
under the prostate. Subjective symptoms, therefore, are 
peculiarly unreliable in vesical stone, as they are for the most 



312 



ELEMENTS OF SURGICAL PATHOLOGY 



part, in practice — and other means must be taken to reach a 
reliable diagnosis. It will be observed that while the symp- 
toms, as given above, are such as would naturally be produced 
by a solid foreign body in the bladder, they are also' pathogno- 
monic of cystitis from other causes. These facts must be 
impressed upon the mind, because there may be all the symp- 
toms of stone, and none present, and no symptoms at all with 
a stone of large size. 

It will not be safe to base a diagnosis on these subjective 
indications. The bladder must be explored, by proper instru- 
ments, every part of it gone over, notwithstanding there are 
sources of error even then. This process is called "sounding" 

The sound is made in many forms, the chief consideration, 
being an expanded head, to give surface for contact with the 
fingers. The term " sounding" misleads the student, as it is 
not so much a. sound as a sensation communicated to the fin- 
gers that is elicited; in fact in many cases there is no sound at 
all. The instrument is made of various calibres, and while 
some are stiff, others are easily bent into any desired curve, 
which is much the best arrangement. Bearing in mind the 
sensitive state of the bladder, and the intolerance of distension, 
the examination had better be made under an anaesthetic. 
The patient being prepared, warm water is to be injected into 
the bladder, in sufficient quantity, remembering its diminished 
capacity. The sound is to be then introduced, precisely as 
the catheter, being first warmed and well oiled. The beak is 
first to be turned under the prostate, as it is there the stone is 
usually found; if nothing is felt, it is then to be turned and 
swept over the whole of the internal surface. A word of 
caution is here needed. The directions for sounding laid down 
in most of the text-books are misleading. The sound is not 
to be rotated on its axis, as there will be danger of lacerating 
the urethra, which grasps it quite firmly. The direction of the 
beak is changed by sweeping the handle round in a circle, the 
prostatic portion of the urethra representing the pivot. This 
does, at the same time, rotate the sound on its axis, so that 
when ready to withdraw it. glance at the mark on the handle 



VESICAL CALCUL] 



313 



to see which way the point is turned. It a stone is found, 
there may be a slight "click" heard, but the commoner sensa- 
tion is a feeling communicated to the fingers. When the 
sense of touch has been sufficiently educated, the character of 
the stone can be determined by the sound, whether a hard 
uric acid, or oxalate, or a soft phosphatic one. Should no 
stone be found in the first examination, others must be had, 
the patient occupying different positions, sitting, standing, 
King on the side and the like. 

The description given of the process might lead to the con- 
clusion that the operation gave certain and definite informa- 
tion; such is far from being the case. In the first place it 
requires skill in the manipulation of the instrument, an edu- 
cated tactile sensibility, and a certain condition of the stone, as 
to size, position, and even composition. The sources of error 
are many, so that the most expert surgeons have erred, diag- 
nosing stone where none existed, and failing to find one when 
present. The commoner sources of error are as follows: 
Mistaking the promontory of the sacrum for a phosphatic 
stone; the sound striking on a ring on the finger of the sur- 
geon, or a button on his own or the patients clothing, or some 
dangling ornament on his watch-guard, or the like. A stone 
mav be overlooked, on the other hand, from its being encyst- 
ed, with the mucous membrane rising high above it; or it mav 
be of very light specific gravity, and float in the w r ater; or 
very small. In short the sources of error are so many that it 
has passed into an axiom, -never make an operation for 
stone without having one in your pocket, to show the family, 
if vou do not find one in the bladder." 

The Treatment is purely operative, there being no field for 
medicine at all, except in the after-treatment, which is as 
laid down in all our text-books. 

Formerly it was considered an unjustifiable procedure to 
make an operation without demonstrating the presence of the 
stone at the time. Now, however, it is proper to open the 
bladder for purely diagnostic purposes, in fact cystitis has 
been cured in that wav. Nevertheless, as the laitv are not 



3i4 



ELEMENTS OF SCJRGICAL PATHOLOGY 



fully informed on the subject, precautions must be had to 
show some result, and to "confirm the diagnosis." 



PROSTATIC CALCULI. 

These are calculi found in connection with the prostate, of 
two kinds, one of them urinary, in the line of our present 
enquiry — the other unconnected with the urine in any way. 
The proper urinary calculi, having relation to the prostate, 
for all practical purposes may be considered as vesical, the 
symptoms, prognosis, and treatment being the same. So also, 
to some extent, with relation to genesis, a nucleus of some 
kind being sine qua non. The commoner origin, probably, is 
from the lodgment of a urinary stone between iL and the blad- 
der; at other times an x encysted vesical stone, in close con- 
tiguity, may grow into the prostate. There. have been cases 
in which the cavity from an abscess, or the partly healed 
wound from a perineal lithotomy has afforded lodgment to 
urine, which has undergone decomposition, and furnished the 
• nucleus. In most cases, the presence of the nucleus sets up 
an inflammation or chronic irritation of the prostate, which in- 
creases its excretion to a degree that the later accretions to 
to the stone are calcareous matter furnished by itself. The 
greater part of all stones in this region are consequently 
formed of carbonate of lime. 

The symptoms produced are not at all pathognomonic, not 
infrequently there are none of any prominence. There are 
the ordinary symptoms of prostatitis, which leading to an ex- 
amination of the gland through the rectum, will reveal con- 
cretions, in many cases. In some instances the stone may be 
situated so deeply, that it cannot be felt through the rectum; 
in others it may project on the urethral or vesical side, so that 
the passage of the sound or catheter will detect it. In any case, 
a diagnosis being made, the sole indication is to remove it pre- 
cisely as though it were vesical, viz., by perineal lithotomy. 

True Prostatic calculi are thus described by Poland 
(Holmes Syst. Surg., iv.,) : "The prostate gland, like other 



URETHRAL CALCULI 315 

glands, is liable to an inspissation of its secretion, producing 
small, yellow, sometimes red. or colorless bodies, scattered 
throughout the follicular structure. These, at first, are said 
to consist of organic matter which ViRCHOW believes to be de- 
rived from a peculiar, insoluble protein substance mixed with 
the semen; but sooner or later these formations are believed 
to irritate the mucous membrane, causing phosphatic deposi- 
tions which become encrusted upon the organic matter, and 
thus the genuine prostatic calculi are formed." 

Cases are noted in which these calculi remain single, attain 
large dimensions, and ultimately convert the gland (by absorp- 
tion and perhaps suppuration), into a more or less thin-walled 
cyst. In most cases they are multiple, sometimes to the extent 
of converting the whole gland -into a ston}- mass." In some 
few cases the portion of gland so affected has become sepa- 
rated from the remainder, and falling into the bladder set up 
symptoms of vesical stone. The treatment is purely surgical. 

URETHRAL CALCULI. 

Stone in the urethra orioinates very much as stone in the 
ureters, viz., eitherjyy lodgment of a renal stone (or portion 
of a vesical stone), or fragments left after a lithotrity; or it 
may originate in the canal from morbid changes that induce 
retention of urine.^and thus favor decomposition. They are 
found at any part of the canal, perhaps among adults at the 
membraneous portion, and among boys in the fossa navicularis. 
The accessibility of the urethra, both for palpation and exam- 
ination with sounds, renders a diagnosis usually a simple mat- 
ter. As might be expected cases of stricture with sacculation 
behind the constriction furnish the greater number of cases. 



XVIII— TUMORS 

Tumors form the subject for almost innumerable essays, 
treatises, and books, constituting a mass of literature that is 
fairly appalling, not only in its magnitude, but in the confusion 
growing out of the diverse doctrines of etiology and related 
topics. Viewed from a purely clinical side, there is little to 
add, it would seem, to what has been quite generally accept- 
ed; from all other' points of view, there is a remarkable lack 
of harmony, notwithstanding the literature, even now pouring 
from the press in a constant stream. From all the circum- 
stances, as above, it may be permitted one who is not without 
considerable experience, in the laboratory as well as the clinic- 
room, to have views of his own on these disputed questions. 
Something, therefore, in the following pages may, and prob- 
ably will, fail to meet the approval of many whose opinions 
are entitled to respect. The attempt will be made, however, 
to treat the subject in a judicial manner. 

A tumor rriay be defined, as a new tissue, laid down in 
more or less intimate relationship to existing tissue; not a 
hypertrophy, or necessarily formed of elements derived from 
the locality. It is a szvel/ing. as the term implies — but it is 
not a local redundancy, and rarely an outgrowth. 

By hypertrophy is understood an overgrowth of tissue, the 
elements remaining as in the normal type; a simple increase 
in magnitude or number of these elements. Tissue that is 
formed, that is adult tissue — is no longer cellular; tumor tissue 
remains cellular, and thus represents immaturity. In other 
words, a tumor stands as an excessive production, with de- 
ficient organization. There is a more satisfactory outcome, as 
to organization, than occurs in inflammation, or abscess, but it 

316 



TUMORS 317 

is so far from perfect, that, as RlNDFLElSCH puts it, "it is a 
mere caricature." The more or less embryonic histology of 
the tissue, gives embryonic characters to its growth. It grows 
more rapidly than normal tissue does, and has no limit, or ter- 
mination. The tumor either grows indefinitely, or after attain- 
ing a certain organization, it breaks down, and is dispersed 
throughout the bodj', cast out entirely, or is the beginning for 
some other form of morbid action. 

The first question to be considered in the study of tumors, 
is the effect on near -part<: how contiguous structures are 
affected by the neoplasma. The consequences are dependent 
upon the grade of development of the tumor, in other words 
its malignancy, as a matter of course, but there are others, 
depending upon different considerations. Perhaps they can 
all be included in the following: Absorption. Displacement, In- 
clusion, Infiltration. 

Absorption, or destruction of the tissues having anatomical 
relationship to the tumor, occurs from two causes, and depends 
somewhat upon the character of the tissues. Soft tissues are 
compressed, or put in a state of tension, in either case atrophic 
changes being the result. The final result will depend upon 
the rate of growth in the tumor. If it is rapid, and continuous, 
atrophv of structures so acted upon will likely occur. If it is 
slow, or intermittent, the parts gradually accommodate them- 
selves to the new relations, and are more likely to become 
hypertrophied. Again the function of the parts involved will 
play an important part. Thus a muscle that is active, and 
essential to common function, like the sterno-mastoid, will 
yield very slowly, and may preserve its structural and physio- 
logical integrity even in the case of large, rapidly growing, 
tumors. Others, such as the piatysma, will more likely under- 
go atrophy. Nerves, as being less elastic than blood-vessels, 
will surfer more than the latter. Another fact is important to 
notice. In a contest between a growing elastic body, and an 
inelastic solid one, while the former is modified by the latter 
in its form, the latter is absorbed or eroded. Frequent ex- 
amples are seen of ribs, cartilage, or even the bodies of ver- 



318 ELEMENTS OF SURGICAL PATHOLOGY 

tebrse, eroded, or absorbed, by aneurysmal tumors. As a 
rule, of course, tumors grow faster in the direction of least 
resistance, but they grow in all directions. This has the effect 
to retard absorption, to some extent, but does not, by any 
means, prevent it. Absorption, usually, is a feature in non- 
malignant growths. 

Displacement, is caused by a tumor growing between con- 
tiguous parts, and pushing them out of their proper relation. 
Surgically this is an important matter, as the topography is 
so altered that operative procedures are apt to be embarrassed. 
Particularly is this true, in the case of tumors of the neck, 
when not only are nerves and blood-vessels often found where 
not expected, but the alteration in the muscles removes the 
most constant guides to organs and structures that are exposed 
to injury. In all such cases, some absorption is likewise going 
on, and the embarrassment to the operator is intensified, as 
structures that it is desirable to avoid, are not only out of their 
proper pcsition, but so altered by atrophic changes that they 
are not readily recognized. Displacement is an indication of 
non-malignancy, as a rule, yet in the early stages of malignant 
tumors it may be present. 

Inclusion, is a term expressive of the fact that a tumor 
envelopes or grows around some near part. This is rare in 
true tumors, but it may occur in cases of rapid growth. It is 
commoner in the case of glandular tumors, where a gland be- 
comes converted into a tumor, such as parotid fibroma, where 
the trifacial nerve, and the internal carotid artery are found 
running up through the tumor mass. In other cases such an 
event is unlikely, as the involved structures would be displaced 
or absorbed, oftener than included. Such tumors may be either 
innocent or malignant, oftener the former, if the term is used 
to indicate some preservation of function in the included part. 

Infiltration means that the elements of the tumor have en- 
tered other structures, displacing the normal tissue. For in- 
stance, whether a part is infiltrated or included, the loss of 
function is apt to be the same. In the latter case, however, the 
change in structure is purely atrophic; in the former the tumor 



ETIOLOGY OF 'i QMORS 319 

elements have found their way into the tissue, and displaced 
the normal elements more or less completely. Such processes 
are always malignant. 

As to the organism as a whole, as will be shown later — the 
considerations are quite different. In some cases nothing but 
discomfort from weight, disfigurement, or interference with 
functions will result, particularly in restricting motion of 
joints. In others, pressure effects are serious, obstructing 
canals, as the air passages — or displacing viscera. In both of 
these cases the disability is local, but is due to purely mechan- 
ical causes. Such tumors are nearly always innocent in type 
and clinical features. In another class of cases, however, the 
tumor elements migrate, and infiltrate distant parts, parts that 
are not in anatomical relationship to the site of the tumor. 
These are quite invariably malignant. In one case we have a 
morbid action, a pathological state; in the other, simplv con- 
sequences of mechanical pressure. 

ETIOLOGY. 

As is so generally the case, the causes for tumor formations 
are to be considered under two heads, the exciting and the 
■predisposing. The latter are, in every way, from all possible 
points of view, the most important, as without their operation 
a tumor would be impossible. 

Exciting Causes: The first essential in the development 
of a tumor, is some hyper-nutrition, in a restricted territory, 
and of only a certain degree of energy. If too energetic, 
inflammation and suppuration w r ould be imminent; if somewhat 
less so a simple hypertrophy; if insignificant there would be 
no result. Added to this essential, there must be something 
disorderly in the organization. Traumatism, we have seen, is 
a simple provocation for repair, The repair being completed 
the unused material is absorbed, or otherwise disposed of, and 
the new tissue starts on a* slow assimilation to the function and 
structure of the part in which it is deposited. In the case of 
a tumor, the elements of repair are furnished, but more than 



320 



ELEMENTS OF SURGICAL PATHOLOGY 



scar tissue, and at the same time less — is the result. The 
traumatism usually is of minor degree, and frequently repeat- 
ed; or, if inflammation does result, it must be low grade, and 
somewhat chronic in type. We find the rule to be, in the case 
of innocent tumors, at least, that they are more common on 
parts of the body subjected to more or less constant irritation, 
as the shoulders or hips; or those parts in which function is 
accompanied by pronounced irritation with hyperemia, as the 
stomach (particularly the pylorus) ; or parts where unlike tis- 
sues meet, as the commissure or vermilion borders of the lips. 
In cases that might be considered more truly traumatic, the 
repair should be irregular, as from faulty coaptation, or in- 
clusion of foreign bodies, or possibly irritation from the dress- 
ings, either during repair, or of the scar, later. But under all 
of these conditions the absolute essential is a lesion of minor 
degree, and only a hyper-nutrition, which must also be of 
chronic character. Even with all these conditions furnished, 
a tumor will not result in the vast majority of cases; the pre- 
disposing factors are the absolute essentials. 

Predisposing; Causes: The conditions, whether constant 
or transient, that render one person more liable than another 
to the development of a tumor, must, in the very nature of 
things, be of the utmost importance as furnishing accurate 
knowledge of the morbid processes going on, as well as de- 
termining treatment. It can readily be conceived that a tumor 
which stands as a symptom of a general dyscrasia, must have 
a very different appearance to one that represents a purely 
local outgrowth. Just what these predispositions are, is not 
always a matter of easy solution, either in general or particu- 
lar. Do we inherit the elements of tumors, or a weak tissue, 
or are they representee of abnormalities in ovular evolution? 
As to the large family of malignant tumors, there are all 
these, and many other theories extant. It seems probable 
that the facts will be found, sometime, to be in harmony with 
all three of them; that is, there is no single predisponent; it 
differs in different cases. For instance, to take up the last 
theory first: Monod and Arthraud, some years ago stated 



ETIOLOGY OF TUMORS 321 

the proposition, that the development of the ovum was rarely 
accomplished in an ideal manner; that the large majority of 
ova never reached their destiny at all. and the few that did so 

arrived there over a more or less disorderly route. To be 
more particular: Assuming the fertilization, and the inception 
of evolution, a perfect progression would mean the development 
of the four blastodermic layers with strict reference to each 
other; that is, that the interior ones would always be smoothly 
applied to the inner surface of those exterior. It is assumed 
by them, that such is rarely the case; that a layer is thrown 
into folds, when too large, or attenuated, at some points, 
when too small, these points remaining as centers of imperfect 
development. It mav be that later in the history of the 
case development may go on. but it will be that much behind 
the remainder of the ovum. It is assumed by them, that the 
defect may remain until the individual has reached any period 
of life, and remain latent, to be awakened into activity by 
some accidental occurrence. The results, as to type of tumor, 
depend entirely upon the particular layer involved. The 
epiblastic layer will give tumors of integumentary elements. 
The mesoblastic, and hypoblastic, will furnish elements nor- 
mally related to those layers. They divide all tumors into two 
grand divisions, the tumors -proper, in which the elements are 
derived from sources given above, and which represent tumors 
that are in some sense hereditary, or at all events congenital. 
The second class are called inflammatory (or trophic) neo- 
plasms, and are of recent, accidental origin. Under the first 
head a classification is made, as follows: 

Teratoma, or ' ; monstrous" tissue, due to an involution, or 
some defect embracing all the layers of the ovum. 

Mixed tumors, where two layers are involved. 

Pure tumors, where a single layer is at fault. 

The histological character of the teratoma would be unlike 
any tissue in the body, containing elements more or less derived 
from all the layers of the blastoderm. While in pure tumor, 
they would be such as would come from a single layer, and 
thus be more "typical." 



322 



ELEMENTS OF SURGICAL PATHOLOGY 



The second class, the trophic or inflammatory neoplasms, 
are representative of a simple proliferation from connective- 
tissue, epithelium, or endothelium. 

The theory is ingenious, and quite captivating, but in addi- 
tion to its being a -pure theory, with very formidable diffi- 
culties in the way of proof — it is not capable of satisfying all 
the conditions. Certain forms of tumor can be readily ac- 
counted for in this way, such as the dermoid C}~st, but many 
others give histories that are not at all in harmony therewith, 

As to the inheritance of a zveak tissue, the teaching of Rixd- 
fleisch takes first rank. It is a fact well known, or at least 
quite generally accepted as such — that structural defects or 
peculiarities, after a certain time, become constant in the off- 
spring, an ebb and flow occurring for a time before the type 
is confirmed. We know of man}' cases, such as supernumer- 
ary fingers, web-fingers, and the like — in which families, even 
in somewhat remote relationship, have some distinguishing 
feature. Occasionally there are relapses to a primitive type 
(atavism). It is conceivable that certain defects due to pure 
accident, will impress themselves so strongly on an organism, 
that the progeny will have, if not a similar one, probably a 
modified function. Of course a modified function is the result 
of imperfect structure, and yet the latter defect may be micro- 
scopic, perhaps not even capable of demonstration. An ex- 
ample is found in the case of hernia; the long traction on the 
mesentery, in cases of long standing, results in lengthening of 
this structure. The offspring may inherit the long mesentery, 
but not the hernia. In course of time the hernia will probably 
appear, the conditions being so favorable. Again, on the other 
hand, a neurosis may be perpetuated in the offspring, and some 
abnormality may later appear. One of the commoner exam- 
ples of <; weak-tissue," is found in cases where parts or tissues 
are preternaturally vulnerable, with no structural explanation 
of the fact. We are all familiar with instances, in which in- 
dividuals are peculiarly susceptible to morbid influences, and 
yet there is no appearance of anything, as far as structure is 
concerned, to account for it. What is true of the organism as 
a whole, can very readily be true of parts ot it. 



ETIOLOGY OF TUMORS 323 

Finally, is it possible to transmit the dements of a tumor 
directly to the offspring? Possibly, but there are few, if any 
facts to support such a hypothesis. The common sentiment, 
I think, is that no form of morbid action, unless it may be 
syphilis, is transmissible in this way. The question of pre- 
disposition, therefore, must be left unanswered, as to the issues 
raised in the foregoing-. Other considerations, however, may 
be stated more positively. 

Sex has an undoubted influence, women presenting more 
cases of tumor, while men give more variety. This is ex- 
plicable when we remember the physiological differences. 
Ovulation, menstruation, lactation, and child-bearing furnish 
crises in the lives of women that never occur to men. The 
frequent irritation of the organs concerned in these various 
functions, furnish all the predisposing essentials to tumor- 
formations, the predisposition thereto being present. 

Age, as influencing the growth of the body, the readiness 
of repair, and the perfection in the result, exercises a very im- 
portant influence. In early life, tumors of the fast growing 
type, and embryonic organization, are common, as the various 
sarcomata. In adult life, the process is more deliberate, and 
the organization more typical, giving benign growths. In old 
age, the material is sparingly furnished, and the organization 
low; the surrounding tissues are vulnerable, of low resistance, 
and malignant growths are common. 

Occupation, as far as it imposes irritation on tissues habitu- 
ally, or interferes with function from habitual position, fre- 
quently cause tumors, of various kinds, depending upon the 
age of the individual, and the predisposition. We often find 
fatty tumors on parts constantly subjected to slight irritation, 
as the shoulders or hips; or cysts, as adventitious bursa 1 , on 
parts subjected to greater irritation, as the hip. shoulder, elbow, 
etc., in the case of miners. 

Mental Conditions are probably more responsible for the 
type of a tumor than is commonly supposed, although the 
data are quite incomplete. It is assumed by many good 
authorities, that mental depression, growing out of isolation, 

X 2 



324 ELEMENTS OF SURGICAL PATHOLOGY 

or grief of anv kind, such as family losses by death, or busi- 
ness reverses, are productive of malignant transformations of 
existing tumors, if not directly causative ab initio. 

Tissues, not so much kind, as location, certainly play a 
most important part. Thus parts that are frequently irritated. 
will more readily take on some kind of abnormal overgrowth, 
than others of the same character more happily situated. Or 
parts that are on the border line between tissues of unlike 
character, when hvper-nutrition occurs, furnish elements 
which give a typical Organization. We know it to be a fact, 
that the secretions of the body are quite generally toxic when 
out of their normal relation, and innocuous when in their 
proper place. Thus the bile, urine, saliva, or blood are abso- 
lutely bland in their proper receptacles, or ordinary channels, 
but produce the most serious consequences when accidentallv 
brought in contact with other tissues, as the peritoneum, or 
even the integument. The same fact holds good in the case 
of tumor elements. An internal proliferation of epithelium 
will give a malignant tumor or ulcer. Thus when unlike tis- 
sues are similarly affected by hyper-nutrition, atypical organi- 
zation occurs, and we have malignant tumors resulting. Thus 
tumors of the pylorus, cervix uteri, commissure of the lips, 
and the like, are usually malignant. 

PATHOLOGY. 

There can be no question, that in the majority of instances, 
tumors commence as purely local affairs. I do not believe 
that the character a tumor will later assume is determined in 
the beginning. All that does occur is a simple hyper-nutrition, 
a purely local cellular activity, the ultimate characters being 
determined by other considerations. Of course there are forms 
of tumor that are malignant or otherwise from the moment 
the process commences, but even then they are local, as to 
formative forces, and for a longer or shorter period of time 
innocent. It was long before this conviction was forced upon 
me, all my teaching having been of quite a different character. 
The first step, therefore, may be assumed to be a strictly 



PATHOLOGY OF TUMORS 325 

local overgrowth, called into activity by a frequently repeated 
traumatism, slight as to intensity. The products are organ- 
ized, instead of being absorbed or otherwise disposed of. as 
would be the case ordinarily, and the kind of tumor resulting 
will depend upon the degree of organization attained, the 
character of the predisposing influences, and the nature of the 
parts involved, to some extent. 

The later history of the case depends upon many things, 
but chiefly, I think, upon the manner of development of the 
tumor. Growing rapidly, there is a promise of low organiza- 
tion: growing slowly, it will be of a higher grade. A steady 
growth, is likely to give a typical character to the tissue, 
while intermittency will probably result in something" abortive. 
It is thought by many that systemic invasion depends upon 
the presence or absence of a capsule; a capsule being formed 
the tumor is probablv innocent, perhaps largely from the bar- 
rier thus furnished to infiltration. The capsule would be much 
more likely to occur in slow, steady growths. The question 
of infection is. however, solely determined by the malignancy 
of the growth. The essential difference as will be shown 
later, is in the tendency of the tumor to disorganization. In 
some tumors, the innocent or typical group — growth goes 
on indefinitely, almost without limit, the tumor finally ceas- 
ing- to grow, or undergoing some form of degeneration, 
from the poverty of its nutrition, blood-supply. In others 
they early break down, and the elements are dispersed, 
through the lymphatics, forming foci in remote regions, with 
reproduction of parent tumor. The question of secondary 
growths has much to do with the question of recurrence after 
removal. A portion of a tumor may undergo atrophy, while 
other portions take on an accelerated growth. At other times, 
in non-capsulated growths, there is infiltration of near parts, 
and migration to distant localities. After removal, it often 
happens that a small portion remaining will serve as a nucleus 
for a recurrent growth. Hence, it would appear, the elements 
of a tumor are little disposed to take on purely normal char- 
acters, or to assimilate themselves to contiguous parts: they 



326 ELEMENTS OP SURGICAL PATHOLOGY 

are entirely without purpose in the organism, and when por- 
tions of them are transplanted, with vitality unimpaired, they 
organize into tumors, like the parent type, with no relation to 
the part in which they are found. By dispersion, therefore, 
a tumor originally purely local, may infect the entire organ- 
ism. Or a tumor may, from its magnitude, make such drafts 
on the body for its maintenance that the general health will 
suffer. Again, it may undergo degeneration, and the slough- 
ing and suppuration incident thereto will exhaust the vitality. 
Still again, by pressure upon, or inclusion of important struct- 
ures, the health of the body may be impaired, even its exist- 
ence threatened, by purely mechanical means. 

Classification is so closely allied to pathology, that it may 
well be considered an essential part of it, inasmuch as it 
includes questions of physical characters, gross and minute, as 
well as clinical and natural history. 

First as to Density: — -We divide all tumors into solid and 
cystic. The former need no description, the term being self- 
explanatory. As to the latter, however, there is much that 
might be written. A cyst is a hollow tumor, the cavity being 
filled with material of differing consistency, from fluid to semi- 
solid masses, derived from the normal secretions of the part, 
more or less altered. Thus one scheme of nomenclature has 
reference to the character of the contents, e. o-., serous, mucus, 
hemorrhagic, atheromatous, sebaceous, dermoid, and the like. 
For practical purposes such a classification is of little value. 
Another classification is into -simple " and "compound;" or 
"unicysts" and " polycysts," also known as " multilocular " 
and -monocular." Still another classification is into "barren" 
cvsts, which are single, or -proliferating," which are polycysts. 
with a further classification of the latter, into "exogenous" 
cysts, where the secondary cysts grow from the exterior of 
the parent cyst; or "endogenous," where they grow from 
w r ithin, into the cavity. The most useful classification, it seems 
to me, to which all the others may be considered subsidiary, 
is into natural, and artificial. 

Natural Cysts, are those which form in a part already 



CLASSIFICATION OF TUMORS 327 

cystic, often from an occlusion or stenosis of the duel, or com- 
mon outlet, giving a retention of the secretions, and known as 
"retention cysts." Again the duct will remain patent, but a 
hyper-nutrition furnishes an amount that the duct cannot 
carry off. The former retention cysts, may be purely acci- 
dental, stricture of the duet being due to traumatism in many 
cases, and thus having no pathological significance. The 
others, represent some pathological state, and are therefore of 
more interest to surgical pathologists. Ranula and sebaceous 
cysts are representative of the former class; and ovarian cysts, 
and hydrocele represent the latter. 

Artificial Cysts are those that are formed in parts not 
naturally cystic, as occurs in the cystic degeneration of solid 
tumors, common in the case of fibroma; or an accumulation in 
connective-tissue spaces. Some writers do not consider these 
latter as cysts at all. or speak of them as " false cysts," or 
'•pseudo-cysts.'' 

Another form of cyst, in its natural history a natural or 
'•true*' cyst, is the so-called dermoid cyst, which claims a little 
more careful consideration. It will be remembered that the 
theory of Monod and Arthraud, referred to in an earlier 
paragraph, of blastodermic involution, was stated to be a suf- 
ficient explanation of the genesis of some forms of tumor, 
while probablv insufficient in the case of very many others. 
The most notable of the former variety are these dermoid 
cysts. The term means, a cystic tumor, the contents of which 
are adult elements, entirely out of relation to the part where 
found. The usual contents are hair, in balls, or matted to- 
gether by sebaceous material, and portions of bone, or teeth. 
Almost any integumentary structures are found, but oftener 
the above. It was supposed, at one time, that these tumors 
were blighted ova, representing either a super- or double- 
fcetation, in which one ovum had become included in the other. 
At another time, it was taught, that the tumor was a blighted 
ovum furnished by the patient in whose body it was found. 
Certain facts, however, have utterly contradicted both of these 
theories. Such tumors have been found in both men and 



328 ELEMENTS OF SURGICAL PATHOLOGY 

women; young children, as well as adults; and in regions en- 
tirely outside of the genital tract, such as on the back. The 
external appearances are not at all different from other forms 
of tumor; it is only when the contents are examined that any- 
thing peculiar is noted. These are various, as already stated, 
and often the elements are found to be normal in one sense, 
(as to structure), and abnormal in another, as to amount. 
Often the masses of hair will be enormous, double that utilized 
in the body; teeth will be found, in sufficient number to supplv 
two individuals. Certainly all the facts as the} T appear to the 
clinician, would bear out the theory that there was an arrested 
development of one, or more, of the blastodermic layers, the 
process starting up later, in obedience to some excitant, and 
growing with the rapidity characteristic of embryonic life, 
soon overtaking the rest of the organism. 

Attachment: A sessile tumor, is one that is attached by a 
broad base. A -pedunculated one, is where the attachment is 
narrow, or constricted. Probably all tumors commence as 
sessile, the pedunculated character being due to many causes. 
The common process is, where tumors grow into a cavity, 
as the bladder, uterus, stomach, or pharynx, from above, or a 
position where they will be pendulous — by traction from 
weight, the attachment is attenuated, and constricted, often to 
an extent that ultimatelv separates them from their matrix 
altogether, the attachment being the attenuated lining mem- 
brane of the part. At first the blood-supply is furnished 
through the pedicle, but as the process advances, this is gradu- 
ally cut off, and new vascular connection is made between the 
tumor and] overlying structures. A pedunculated tumor is 
rarely malignant, perhaps never. Sessile growths may be 
either innocent or malignant. 

Relations. — The relations a tumor sustains to near parts are 
of the utmost importance in determining malignanc} T , and 
consequently in the selection of treatment. In this classifica- 
tion the terms encysted, or encapsulated — and dijfused are used. 
The former having an envelope, or capsule of some kind, 
separating it from surrounding parts, the latter being more or 



CLASSIFICATION o\' Tt MORS 329 

less incorporated with near structures- As to malignancy, 
the encapsulated forms are oftener innocent, the diffused the 
reverse, although there are instances to the contrary in both 
Tiie question of interest is the manner in which this 
capsule is formed, whether natural or adventitious, as the clin- 
ical characters, as to malignancy, are intimately connected 
therewith. It will be noted, at the outset, that while innocent 
tumors are encapsulated, as a rule, yet malignant ones may 
be also, in the commencement, the capsule being destroyed 
later. The natural capsule, would be such a structure as 
occurs in a gland, the tumor gradually displacing the elements 
of the gland retaining the capsule. In some instances the 
capsule remains, accommodating itself to the growth of the 
tumor; in others it will disappear by absorption, and the 
tumor become diffuse. In the former case, the tumor is 
probably innocent, or if malignant histological!}', is innocent 
clinically as long as the capsule remains intact. In the latter, 
the tumor is oftener malignant, although in rapidly growing 
tumors it may be innocent. Another form of natural cap- 
sule will be noted where tumors deyelope in cayities, or 
spaces beneath dense fascia, or under broad muscles. Here 
the histological characters of the capsule will become gradu- 
ally modified, adhesions will form between it and the tumor, 
and the structure remain as a capsule pure and simple, haying- 
lost all of its original character and function. Such tumors 
are oftener malignant, although they ma}' be innocent. When 
malignant, howeyer, the capsule is very apt to be destroyed 
later, and the tumor become diffused. 

Adventitious Capsules are formed in two ways chiefly, 
possibly three. In one case, the growth of the tumor being 
slow, the peripheral cells become organized, and assume 
fascia-like characters. Again, there may be a proliferation 
from the surrounding parts, possiblv an inflammatory exudate. 
and a membrane is formed precisely as occurs in pelyic abscess 
as a limiting wall. Still again, the growth of the tumor will 
compress overlying tissues, attenuating them individually, but 
compressing and condensing them into a single layer. Later 



330 ELEMENTS OF SURGICAL PATHOLOGY 

the irritation from the increasing size of the tumor will set up 
a cellular proliferation, and the perpetuity of tissue confirmed, 
but as something very unlike its original character and pur- 
pose. In malignant growths, therefore, in parts where a 
natural capsule is not to be looked for, an adventitious one, if 
formed at all, must be very short-lived, and of feeble organiza- 
tion. From the above facts, it would appear that the absence 
of a capsule would quite surely indicate malignancy, while its 
presence in tumors of any size, or that existed for any time 
would quite as surely promise innocency. 

Form: — All tumors have a tendency to the globular form 
in their ineipiency; as time goes on they assume various forms, 
depending upon their surroundings, the manner of growth, and 
the clinical characters. Thus an innocent tumor will preserve 
the globular character, as a rule, until it meets with some 
resistance, as the walls of a cavity, or dense fascia, when it 
takes a form determined by the character of the obstruction. 
A tumor may, again, by some irritation acting upon one part 
more than another, grow more rapidly in one portion than 
another, and thus assume an irregular form; or it may be 
pendulous, and assume a pear-shape; or it will meet less resist- 
ance in one direction than another. It may, finally, assume a 
shape characteristic of its type, as the square form so common 
to scirrhus, or the nodulated characteristic of chondroma or 
encephaloma. As a rule, the more regular the outline, and 
the smoother the surface, the greater is the probability that the 
tumor is innocent. 

We now reach the final classification, and the one essential,, 
above all others, to a proper understanding of the subject. It 
is difficult to separate this from other classifications, but there 
is no convenient word to express it. The whole matter of 
classification may be included under two heads, the clinical and 
the anatomical or histological. Sometimes they have been 
called the "English" and the '-German." 

Clinical Classification is based upon the natural history, 
macroscopic characters, and manner of growth very largely, 
tumors being classed with reference to their malignancy. 



CLASSIFICATION OF TUMORS 



333 



From this point of view there are two great families of tumors. 
those that are malignant, and those that are not. Strictly 

speaking, however, there is an intermediate class, partaking oi 

some of the features of both, so that the custom has been to 
classify tumors, under this system, as innocent (benign, non- 
malignant), semi-malignant and malignant. The advantage in 
this method is, that some conception of the kind of tumor, as 
to malignancy, can be had prior to operation, an important 
consideration as to probability of recurrence, and the possibil- 
ity of there being systemic infection. Furthermore the kind of 
operation to be made, whether with sacrifice or saving of 
tissue, will be determinable by the ability to place the particu- 
lar case in its appropriate class. There is a disadvantage, 
however, but one of very minor importance, in the inability to 
determine the exact species. For therapeutic and prognostic 
purposes, however, this amounts to but little. The characters 
by which the malignancy of tumors can be determined are 
something as follows: 

Non-Malignant. — Nearly, or quite all the cysts, especially 
the •■ natural cvsts," are found in this group. Also the pedun- 
culated and encysted. If tissues are simply displaced, included, 
or absorbed, and not infiltrated, the presumption is always 
in favor of innocencv. There must be a careful interroga- 
tion of symptoms of systemic disturbance, to distinguish 
between those due to simple " pressure effect,' 7 and those to 
dispersion or migration. Furthermore this class of tumors 
are quite generally single though this is not by any means an 
invariable rule. Pain is seldom a symptom, and if there 
should be any, it is probably due to pressure or tension of 
nerves, and very likely to be reflex, or at all events evidently 
not in the tumor itself. The tumor is movable: near parts 
are not implicated: the skin is non-adherent, and not discolor- 
ed: the growth is irregular, or rather, intermittent, and slow. 
In shape they are usually symmetrical, or retain the shape 
given them by their surroundings. There are no deposits at 
a distance, no glandular infiltration, and no "'cachexia/' When 
removed they have no tendency to recurrence, unless some 



332 



ELEMENTS OF SURGICAL PATHOLOGY 



portions are left behind. They do not destroy life, unless it 
may be by pressure on important structures. The most 
notable of the more constant features, probably, will be the 
tendency to grow indefinitely, rarely undergoing degeneration, 
unless some accident occurs that interferes with their nutri- 
tion. In addition to the cysts the most common types of inno- 
cent tumors are the fatty, the myomatous, fibrous, and the 
like. It is generally considered to be a symptom of be- 
nign ancy, when a tumor is very large, Certainly the rule is, 
that the larger the tumor the more certainly is it not malig- 
nant. They occur at all periods of life, but oftener in the 
adult subject; on section they resemble normal tissue. 

Semi-Malignant: — These tumors are oftener seen in young 
subjects, but occur at all periods of life, more rarely in ad- 
vanced age. The growth is rapid, sometimes intermittent,, 
but oftener continuous. The;\ T are painful, have a tendency to 
destroy life, and always accompanied by some marked depre- 
ciation of health. They are irregular in form, deeply adher- 
ent, diffused; soon implicate the skin, which becomes discolored 
and traversed by tortuous veins; extend by secondary depos- 
its in the near neighborhood, and have a marked tendency to 
undergo degeneration, breaking down into destructive, and 
persistent ulcers. After removal they are prone to recur, 
either as a reproduction of the tumor, or an ulcer, but usually 
in the scar. It is possible for a benign tumor to undergo a 
transformation into a semi- malignant one, from causes not per- 
fectly understood, but probably from interference with its 
nutrition, not sufficient to destroy its vitality. This seems 
reasonable from the fact that the structure is embryonic, of 
low organization. In this group will be found the sarcomata, 
of various kinds. Section shows resemblance to embryonic 
tissue. 

Malignant: This group of tumors are the so-called "carci- 
nomata," or what is popularly known as cancer. They have 
characters that are almost unmistakable, when fully developed, 
but which may be less pronounced in the early stages. They 
are to be studied in two forms: the occult and the open. or. in 



CLASSIFICATION OF TUMORS 333 

other words, the tm?ior, and the ulcer. It also serves a useful 

purpose to classify them as primary and secondary. 

The Tumor is usually diffused, of slow, steady growth, 
soon becoming attached firmly to adjacent parts; of square 
outline, or very irregular form, occurring, for the most part, 
after the middle period of life. The}' have a slow steady 
growth, infiltrating near parts, and have a tendency to dis- 
persion, evidenced by glandular enlargements. Systemic 
disturbance, or cachexia, is due to this dispersion of the ele- 
ments, and the same causes - give secondary deposits and 
tumor-formation in distant parts. On section such tumors 
are seen to be more highly organized than the semi-malignant 
group, but unlike any normal tissue of the bod)'. There is a 
marked tendency to degeneration, and the ulcers thus formed 
are deep, inveterate, and painful. There is little question, in 
mv mind, that such tumors frequently appear as a degenerated 
recurrence of some less malignant form. At least it is appar- 
ent that all tumors commence, as a rule, with innocent 
characters, so far as mobility, encapsulation, and relation to 
near parts are concerned. There are cases, net few in 
number, when frequent removal has occurred, where each 
recurrence has been of a lower type than the preceding; this 
gives color to the supposition that degeneration in type is not 
improbable, to say the least. The terms -primary and second- 
ary, as applied to the tumor form, are self-explanatory, at 
least as to the former. The latter refers to tumors that 
appear as recurrent, usually in the scar or its near neighbor- 
hood, or in distant parts by migration or dispersion. The 
usefulness of the classification lies in the fact that secondary 
growths are proofs of systemic infection, and operation of 
any kind is therefore contra-indicated. There are many 
varieties of malignant tumors, and it is commonly held that 
the secondary growths are quite generally of lower type than 
the primary. 

The of en stage, is that of ulceration. Shortly before this 
commences, if not before, the surface of the tumor becomes 
uneven, nodulated, and the integument becomes firmly attached, 



334 ELEMENTS OF SURGICAL PATHOLOGY 

so much that it cannot be raised up. The surface is covered 
by tortuous veins, and the skin discolored. Deep attachments 
also form, so that the mass is absolutely immovable. Later, 
the nodules soften on the apex, the skin is destroyed, by a 
sort of ulcerative process, and deep openings form, discharg- 
ing a thin, ichor us, and more or less offensive material. 
These openings gradually coalesce, until a large ulcer forms, 
with high edges, irregular outline, hard and indurated areola, 
and exceedingly painful, particularly at night, or after contact. 
Glandular infiltration now goes on rapidly, and cachexia is 
soon established. Occasionally individual glands soften and 
ulcerate, but as a rule few of them undergo this degeneration. 
There are cases, now and then, all too few in number, in 
which the tumor atrophies, and disappears, either bv slow 
absorption, or is cast out bodily. 

A peculiarity in the growth of malignant tumors, particu- 
larly scirrhus — is that as the tumor increases in size, the parts 
in which it is lodged diminish. Thus in mammary carcinoma, 
the breast is constantly diminishing, as the tumor-elements 
displace those of the gland; while in innocent growths, the 
reverse is a rule. 

Anatomical Classification. — This is also known as the 
-histological,'' and is an attempt to classify tumors with 
reference to their structure, or microscopic characters. For 
practical purposes such a classification is of little worth, as if 
relied upon exclusively nothing could be definitely told about 
a tumor until it had been removed from the body. For pur- 
poses of diagnosis, without reference to clinical characters, 
the method is unsatisfactory, as microscopic evidence is very 
misleading if relied upon exclusively. I much doubt, if a 
microscopist could infallibly place a tumor section in its 
proper place, if he had nothing but the single slide to depend 
upon and no clinical history, or the tumor itself for inspection. 
For this reason, among others: A tumor, of course, is of 
different ages in different parts of its mass. The youngest 
portions are on the surface; the older at the center. Now 
the younger parts of all sarcomata are round-celled; the older 



CLASSIFICATION OF TUMORS 335 

parts are possibly spindle-celled. A section taken from one 
part would not give accurate information, as a round-celled 

sarcoma must be such throughout its whole mass. Again, 
the younger parts of a fibroma, would resemble very closely 
the spindie-celled sarcoma. The method, however, has a 
certain value, at least for scientific purposes, albeit it lacks 
much in the interest of therapeutics. 

Tissue that is completed is no longer cellular, in the sense 
that embryonic tissue is. It is true, by proper treatment the 
cellular characters can be demonstrated, but the fact remains 
that finished tissue is no longer cellular. Tumor tissue, in 
most of the forms, is distinctlv cellular: there is an attempt 
to make a tissue, where tissue is not needed, but it is abortive 
and remains more or less short of the type. The anatomical 
method attempts to classify tumors with reference to their 
resemblance to normal structures, using the terms typical and 
atypical, to indicate their nearness to or remoteness from the 
normal type. The nearer the structure approaches the normal 
type, the greater the innocency. This is an unsatisfactory 
classification, however; it is too narrow. A more satisfactory 
one w r ould seem to be something as follows, making three 
classes, corresponding to the clinical method. 

Homologous Tumors correspond to the benign group; they 
are typical also, as to the tissue with which they are in relation. 
The class includes such growths as the fibroma, lipoma, papil- 
loma, condyloma, steatoma, chondroma, osteoma, myxoma, 
neuroma, angieoma, and the like. 

Heterologous Tumors correspond to the semi-malignant 
(sarcomatous) group, and are atypical as to the surrounding 
tissue, but may be typical as to tissues normal elsewhere in the 
bodv. In structure, however, they are embryonic, of low r 
organization. The sarcomata (round-celled, giant-celled, 
and spindle-celled), epithelioma, and the chondroid and osteoid 
tumors with sarcomatous characters, belong in this group. 

Teratoma. — These tumors correspond to the malignant 
group, and are atypical as to the organism, not resembling any 
tissue normal to the body. They are represented bv scirrhus, 
colloid, encephaloid, and melanotic growths and deposits. 



336 ELEMENTS OF SURGICAL PATHOLOGY 

The necessary limitations of a work uf this character forbid 
any attempt to describe the numerous varieties of tumor- 
formations under their various heads. For this purpose spe- 
cial works must be consulted. The ability to place any given 
tumor in the proper class, is all that can be asked of the 
clinician and therapeutist, the exact variety in the species 
being matter of comparatively little moment for practical pur- 
poses. It will serve a useful purpose to remember that 
typical is a term used with a double meaning; 'it may refer to 
the matrix, and the tumor will be an innocent one; it may re- 
semble normal tissue, but out of its place, and be atypical as 
to the matrix, and typical to the organism, and yet be semi- 
malignant because of its misplacement. 

As already said, for practical purposes it is rarely necessary 
to do more, in the diagnosis of tumors, than to place the exist- 
ing one in its proper family relationship. All varieties of 
tumor of one family, present many, or nearly all, of the char- 
acteristic features, one quite like the other. It is true that a 
fibroma, while benign, often undergoes degeneration, com- 
monly becoming cystic: also that there is a difference in the 
malignancy of the sarcoma; and some difference in the rapid- 
ity of growth and development in the varieties of the malig- 
nant group. At the same time, as to danger to life, and 
liability to recurrence, the essential characters are the same. 
The table, on the following page, therefore, may be useful 
in fixing the malignancy in any given case. 

Prognosis: — As to tumors in general, prognosis is good, as 
to recurrence, when they are removed while in the innocent 
stage, provided no portions are left behind. As to malignant 
tumors, however, the prognosis must always be guarded, even 
if the stage is apparently innocent, as it is often impossible to 
determine whether dispersion has occurred or not, until some 
time has elapsed. The smallest portion remaining, even if 
microscopic in size, will probably prove the center for new 
development, and the new growth is very often more vigorous 
and rapid than the old one, on account, I have thought, of the 
irritation of the operation. After dispersion, a cure is not to 
be expected, and I have ceased to attempt anything operative. 



CLINICAL CHARACTERS OF TUMORS 



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338 ELEMENTS OF SURGICAL PATHOLOGY 

Therapeutics: — -For many years I was an ardent advocate 
for the use of remedies, in all cases of tumor, and had suc- 
ceeded in curing, or greatly improving a considerable number. 
A larger experience, however, has very greatly changed my 
views. I now advise, most strenuously,- the removal of all 
tumors, no matter what their type, when they are in a local 
stage, confining the use of remedies to those that are inoper- 
able. Many will criticise such a teaching, no doubt, and pos- 
sibly accuse me of want of loyalty to my therapeutic creed. 
But the fact remains, that an adherent tumor, where dispersion 
has commenced is inoperable, as a rule, and the failure of 
remedies is only assured when such a stage has been reached. 
We have lost the favorable opportunity, and it can never be 
regained. It is a pure sentimentalism to talk about the muti- 
lation of the body, as a tumor is not a normal part of the body; 
it is an excrescence, and no matter how innocent it may be 
when seen, no man can tell what its characters may be in a 
week or a month. I would not dare advise any one, with a 
tumor that could be safely removed, to delay a day: I should 
feel guilty of a crime to counsel delay. Even in the case of 
an organ that has become invaded by tumor elements, the 
organ is already lost to the economy, and to ailow it to remain 
is to invite a danger that we are powerless to combat. In a 
few words, therefore, while admitting all that the most enthu- 
siastic therapeutist can claim, and admitting freely that reme- 
dies have cured many tumors, I must also admit that they have 
as often, yes, qftener, failed, and when the fact of failure is 
evident, there is nothing to be done, in the case of malignant 
tumors, but render the pathway to the grave as easy and pain- 
less as possible. Our treatment by remedies must be reserved 
for the inoperable cases, and of them there is no lack. 

There are operations, however, less radical than excision, 
that may be forced upon us in these cases of inoperable tumors. 
Some of them are as follows: 

Ligature of feeding vessels, as the uterine artery in uterine 
fibroma. 

Oophorectomy, to hasten the menopause, or bring it on 
prematurely, in the same class of tumors. 



TREATMENT OF TUMORS 339 

Castration, in prostatic tumors or hypertrophy of that 
gland. 

Other measures that commend themselves, are injection 
(subcutaneous) of Methylene blue, in a one per cent, solution, 
in the periphery of the tumor. Mosetig Moorhof has had 
a somewhat extensive experience with this agent, and it would 
appear that many cases of malignant tumor, chiefly sarcoma, 
had been cured thereby. The injections are made every 
other day, and the results, while still not constant, have been 
so good that there is a hope that a remedy has been found 
for some species of sarcoma. 

Dr. W. B. Colev [JVejv 2'ork Med. Record, January 24th, 
1893), gives a record of ten cases of malignant tumor im- 
proved or cured by the occurrence of erysipelas. Two cases 
have occurred, in my practice, where erysipelas appeared 
spontaneously, and for a long time the tumor remained station- 
'ary in one case, and was diminished in size in the other. In 
both, however, the disease ultimately advanced to the custom- 
arv conclusion. Experiments have been made of injections 
with pure cultures, as well as the bacillus -prodigiosus, but the 
results were negative. It would seem that the favorable cases 
were those in which the erysipelas appeared spontaneously, 
but even here, later reports would indicate, the results were 
not curative. 

Electrolysis has been tried, with varving results, in myo- 
mata of the uterus, and fibrous tumors. Many cases have un- 
questionably been cured, and it would seem that the remedy 
promises much. In the case of cysts the curative results are 
marked, particularlv in serous cvsts. My own experience 
with this agent is small, and not worthy of record. 

Among remedies, my most gratifying results have been 
with the black iodide of lime. 1 dr. dissolved in 8 oz. of water. 
The action of light being to decompose the drug, it should 
always be prepared from an unbroken package, and the solu- 
tion kept in a dark place, or the bottle painted black, or cov- 
ered with a black cloth. The dose is a dessert-spoonful, four 
times a day. In fibroma, particularly uterine. I have had 

Y 2 



340 ELEMENTS OF SURGICAL PATHOLOGY 

most remarkable results. My experience has been, I think, 
that it is particularly indicated in the bleeding forms, and 
before any degeneration has occurred. The remedy has been 
used in all attenuations, high and low, but the crude black 
powder, is the only preparation that has been of the slightest 
service. 

Among the more legitimate remedies, Arsenic must take 
first rank, in all forms of carcinoma, but particularly in the 
open stage of scirrhus, and encephaloma. I have had satis- 
factory results, if not in a cure at least improvement, in almost 
all attenuations up to the 30. Perhaps the best have been 
in the use of it as suggested by Prof. Mitchell, the 2 X exter- 
nally, and the 6 X internally. In the majority of cases, after a 
few days the applications seems to cause much pain, and I 
have always stopped its use for a few da] T s at such times. 

Baryta carb., Secale, Phytol dec, Thuja and Sul-phur have 
been credited with cures of tumors of various kinds, but the 
clinical records are meagre, and my experience has not been 
very satisfactory. Hydrastis long enjoyed what I am forced 
to believe a fictitious reputation; particularly in the cure of 
carcinoma; I have never had the faintest indication of benefit 
from its use. 



INDEX 



Abscess, 126. 

acute, 127. 

chronic, 133. 

diagnosis, 133. 

diffused, 136. 

encysted, 127. 

multiple, 183. 

visceral, 132. 
Adenitis, acute, 1S9. 

chronic, 195. 
Adjuvant therapeutics, 39. 
Analytical diagnosis, 12. 
Anaemia, 51. 

ischsemia, 5S. 

pathological, 52. 

physiological, 52. 

surgical, 55. 
Anamnesis, 13. 
Angeioleucitis, 188. 
Arteries, degeneration of, 20S. 

inflammation of, 203. 

pathology of, 201. 
Atheroma, 209. 

Blood-vessels, pathology of, 202. 

arteritis, 203. 

atheroma, 209. 

atrophy, 202 . 

degeneration of, 205. 

hypertrophy, 202. 

phlebitis, 206. 
Bubo, chancroidal, 269. 

gonorrhoea!, 252. 

syphilitic, 277. 

Calcification of arteries, 20S. 



Calculus, urinary, 289. 

prostatic, 314. 

renal, 29S. 

uretal, 306. 

urethral, 315. 

vesical, 310. 
Carcinoma, 332-5. 
Causes of morbid action, 15. 
Chancre, 276. 
Chancroid, 265. 
Chordee, 247. 
Chronic abscess, 130. 

adenitis, 195. 

gangrene, 163. 

inflammation, 118. 
Conjunctivitis, gonorrhceal, 259. 

Degeneration of arteries, 20S. 

atheroma, 209. 

calcification, 20S. 

fatty, 208. 
Diagnosis, 1 1. 

analytical, 12. 

synthetical, n. 

Epididymitis, gonorrhceal, 254. 
Etiology, 15. 

exciting causes, 25. 

immaterial causes, 22. 

material causes, 16. 

predisposing causes, 23. 

Fistula, lymphatic, 19c. 

Gangrene, acute, 159. 

chronic, 163. 
Glandular hypertrophy, 195. 



34* 



34 2 



INDEX 



Gonorrhoeal inflammation, 189-195. 
Gleet, 252. 
Gonorrhoea, 240. 

conjunctivitis, 259. 

ophthalmia, 258. 

rheumatism, 257. 
Granulation, union by, 78. 

Herpes preputialis, 253. 
History, in diagnosis, 13. 
Hydro-nephrosis, 307. 
Hyperaemia, 60. 

pathological, 65. 

physiological, 61. 

reparative, 69. 

Inflammation, 84. 
acute, 86. 

etiology, 10S. 
pathology, 95. 
prognosis, 114. 
semeiology, 86. 
terminations, 115. 
chi onic, 1 18. 
Isehaemia, 58. 

Keloid, S3. 

Lithiasis, 289. 

general, 289, 

prostatic, 314. 

renal, 298. 

uretal, 306. 

urethral, 3 [5. 

vesical, 310. 
Lymphatics, pathology of, 188. 

glandular hypertrophy, 195. 
inflammation, 195. 

inflammation, 188. 

lymphangiectasis, 196. 

lymphoragia, 196. 

Morbid action, 2. 

constructive, 5. 
destructive, 5'. 
genesis, 2. 
idiopathic, 7. 
specific, 8. 
symptomatic, 8. 
trophic, 5. 



Mortification, 158. 

gangrene, acute, 159. 

chronic, 163. 
necrosis, 158. 

Nerves, pathology of, 211. 

atrophy, 234. 

hypertrophy, 234. 

neuralgia, 211. 

neuritis, 232. 

sclerosis, 234. 

softening, 234. 
Nephralgia, 300. 
Nephro-lithiasis, 298. 
Neuralgia, 211. 
Neuritis, 232. 
Neuroma, 233. 

Ophthalmia, gonorrhaeal, 258. 
Orchitis, 254. 
Oxaluria, 299. 

Pathology, general, 10. 
Phlebitis, 206. 

adhesive, 206. 

diffused, 207. 

ephemeral, 206. 
Prognosis, 32. 
Prostatic calculus, 314. 
Purulent absorption, 165. 

secretion, 123. 
Pyaemia, 177. 
Pyo-nephrosis, 304. 

Reflex pain, 48. 
Renal lithiasis, 298. 
Repair, surgical, 67. 
Rheumatism, gonorrhoeal, 257 

Sarcoma, 332-335. 
Scarring, 69. 

defects in, 81. 
Scirrhus, 332-5. 
Sclerosis of nerves, 234. 
Semeiology, general, 28. 

essential, 29. 

objective, 30. 

subjective, 30. 
Semi-pathological states, 44. 
Septicaemia, 165. 



[NDEX 



343 



fie disease s, S 

ulcers, 
Stricture urethral, 262. 
Suppuration, [33. 
Sympathy , 48. 
Synthetical diagnosis, 11. 
Syphilis, 272. 

constitutional, 285. 

primary, 272. 

secondary, 285. 

tertiary, 285 . 

Therapeutics, general, 38. 

adjuvant, 39. 
instrumental, 41. 
mechanical, 41. 
medicinal, 39. 
palliative, 38. 
Toxaemia, surgical, 165. 
pyaemia, 177. 
septicaemia, 165. 
Tumors, 316. 

atypical, 335. 
benign, 331. 
carcinoma, 332-335. 
causes, exciting, 319. 

predisposing, 320. 
clinical characters, 330. 
cyts, 326. 

artificial, 327. 

natural, 326. 
diffused, 32S. 
encapsulated, 329. 
heterologous, 335. 
homologous, 335. 



Tin 



malignant, 322 . 

non-malignant, ^2 1. 
pathology of, 334. • 
pedunculated, 32S. 
recurrence of, 333. 
sarcoma, 332-335. 
semi- malignant, 332. 
sessile, 328. 
solid, 326. 
teratoma, 335. 
typical, 335. 

Ulceration, 137. 

causes, 138. 

classification, 143. 

common characters, 138. 

idiopathic, 144. 

specific, 148. 

svmptomatic, 146. 
Uretal calculus, 306. 
Urethral calculus, 315. 

stricture, 262. 
Urethritis, simple, 238. 

specific, 240. 

Veins, inflammation of, 206. 
Varicose ulcer, 147. 
Venereal contagion, 236. 

chancroid, 265. 

gonorrhoea, 240. 

syphilis, 272. 
Vesical calculus, 310. 
Visceral abscess, 132. 



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